Parp-1 and methods of use thereof

ABSTRACT

The invention is directed to roles for low doses of PARP-1 inhibitors and synergistic combinations thereof to treat disease.

PARP-1 AND METHODS OF USE THEREOF

This application claims benefit of U.S. Provisional Application62/792,373. Filed on Jan. 14, 2019, and is a Continuation-in-Part ofU.S. application Ser. No. 16/564,735, filed on Sep. 9, 2019, which is aContinuation-in-Part of International Application No. PCT/US2018/021855,filed on Mar. 9, 2018, which claims priority from U.S. ProvisionalApplication No. 62/469,436 filed on Mar. 9, 2017, the contents of whichare incorporated by reference herein in their entireties.

All patents, patent applications and publications cited herein arehereby incorporated by reference in their entirety. The disclosures ofthese publications in their entireties are hereby incorporated byreference into this application in order to more fully describe thestate of the art as known to those skilled therein as of the date of theinvention described and claimed herein.

This patent disclosure contains material that is subject to copyrightprotection. The copyright owner has no objection to the facsimilereproduction by anyone of the patent document or the patent disclosureas it appears in the U.S. Patent and Trademark Office patent file orrecords, but otherwise reserves any and all copyright rights.

GOVERNMENT INTERESTS

This invention was made with government support under Grant Nos.R01HL072889, P30GM114732, P20GM103501, and P30GM106392 awarded by theNational Institutes of Health. The government has certain rights in theinvention.

FIELD OF THE INVENTION

This invention is directed to roles for PARP-1 in disease.

BACKGROUND OF THE INVENTION

Colon cancer is complex and involves a large number of genetic andenvironmental factors such as mutations in specific genes and chronicinflammation. In familial adenomatous polyposis (FAP) syndrome,mutations in both alleles of the APC gene that result in itsinactivation are considered one of the initial events in colorectalcarcinogenesis. It is not clear whether this type of cancer is driven bychronic inflammation although inflammation manifests itself during thecourse of the disease. Several studies showed conflicting results on theeffect of anti-inflammatory conditions on APC^(Min/+)-driven tumorburden. In carcinogen/chronic inflammation (AOM/DSS)-driven coloncancer, most of the anti-inflammatory factors prevent or reduce tumorburden in mice.

SUMMARY OF THE INVENTION

Immunotherapy is increasingly regarded as a critical approach to treatmany forms of cancers. Its efficacy is sometimes a limitation. Given therole of PARP-1 in the function of MDSCs and the ability of partial PARPinhibition to reduce the suppressive activity of these cells, it isconceivable to use PARP inhibitors at a dose that can be gaged accordingto the type of cancer and affected patient to achieve a better clinicaloutcome with immunotherapy approaches. It is also conceivable to usethis approach (i.e. partial PARP inhibition) with therapies whosetargets do not include DNA repair/damage.

Aspects of the invention are directed towards a method for treating atumor in a subject.

Aspects of the invention are further directed towards a method ofreducing progression or promoting regression of a tumor in a subject.

Still further, aspects of the invention are directed towards a method ofreducing cellular proliferation of a tumor cell in a subject.

In embodiments, the tumor comprises a solid tumor or a liquid tumor. Atumor can be benign, premalignant, or malignant. In embodiments, thetumor does not comprise a mutation in a BRCA gene, nor is the tumorconsidered a “triple negative” cancer based on negative oestrogenreceptor (ER), progesterone receptor (PR) and human epidermal growthfactor receptor-type 2 (HER2) expression A tumor can be one that isinfluenced by the immune system. A tumor can be a primary tumor, or ametastatic lesion. Non-limiting examples of cancers that are associatedwith tumor formation comprise brain cancer, head & neck cancer,esophageal cancer, tracheal cancer, lung cancer, liver cancer stomachcancer, colon cancer, pancreatic cancer, breast cancer, cervical cancer,uterine cancer, bladder cancer, prostate cancer, testicular cancer, skincancer, rectal cancer, and lymphomas. Non-limiting examples of liquidtumors comprise neoplasia of the reticuloendothelial or haematopoeticsystem, such as lymphomas, myelomas and leukemias. Non-limiting examplesof leukemias include acute and chronic lymphoblastic, myeolblastic andmultiple myeloma. Typically, such diseases arise from poorlydifferentiated acute leukemias, e.g., erythroblastic leukemia and acutemegakaryoblastic leukemia. Specific myeloid disorders include, but arenot limited to, acute promyeloid leukemia (APML), acute myelogenousleukemia (AML) and chronic myelogenous leukemia (CML). Lymphoidmalignancies include, but are not limited to, acute lymphoblasticleukemia (ALL), which includes B-lineage ALL and T-lineage ALL, chroniclymphocytic leukemia (CLL), prolymphocytic leukemia (PLL), hairy cellleukemia (HLL) and Waldenstrom's macroglobulinemia (WM). Specificmalignant lymphomas include, non-Hodgkin lymphoma and variants,peripheral T cell lymphomas, adult T cell leukemia/lymphoma (ATL),cutaneous T-cell lymphoma (CTCL), large granular lymphocytic leukemia(LGF), Hodgkin's disease and Reed-Sternberg disease.

In embodiments, the formation and/or growth of the tumor is exacerbatedby chronic inflammation, the amount of which is dependent upon tumortype.

In embodiments, the method comprises administering to the subjectafflicted with the tumor a low-dose, therapeutically effective amount ofa PARP inhibitor compound.

In embodiments, the PARP inhibitor compound inhibits the enzymaticactivity of one or more proteins in the PARP family of proteins. Forexample, the PARP inhibitor compound inhibits the enzymation activity ofPARP-1, PARP-2, PARP-3, PARP-4, PARP-5a, PARP-5b, PARP-6, PARP-7,PARP-8, PARP-9, PARP-10, PARP-11, PARP-12, PARP-13, PARP-14, PARP-15,PARP-16., or any combination thereof. In specific embodiments, the PARPinhibitor compound inhibits the enzymatic activity of PARP-1, PARP-2,PARP-3, or any combination thereof

In embodiments, the enzymatic activity inhibited by a PARP inhibitorcompound comprises poly(ADP-ribosylation).

In embodiments, the PARP inhibitor compound comprises a compound ofFormula (I):

In embodiments, the PARP inhibitor compound is a compound of Formula(I):

In embodiments, a subject is administered a PARP inhibitor compound at alow dose, therapeutically effective amount. For example, the low dose ofa PARP inhibitor comprises a dose that is about 10×, 20×, 30×, 40×, 50×,60×, 70×, 80×, 90×, 100×, 110×, 120×, 130×, 140× or 150× lower than whatis currently prescribed.

Embodiments of the invention comprise a dose of about 1 mg per day,about 5 mg per day, about 10 mg per day, about 15 mg per day, about 20mg per day, about 25 mg per day, about 30 mg per day, about 35 mg perday, about 40 mg per day or about 50 mg per day.

In embodiments, a subject is administered a PARP inhibitor compound at alow dose, therapeutically effective amount that reduces the enzymaticactivity of a PARP between about 10% reduction in activity and about 50%reduction in activity, but nevertheless does not abolish enzymaticactivity. Specifically, the method as described herein pertains toadministering to a subject a low dose, therapeutically effective amountof a PARP inhibitor compound that reduces the poly(ADP-ribosyl)ationactivity of PARP-1 by about 10%, about 20%, about 30%, about 40%, orabout 50%. In other embodiments, the PARP inhibitor compound reduces theenzymatic activity by about 60%, about 70%, about 80%, about 90%, orabout 100%, but does not abolish the enzymatic activity of the PARP. Inembodiments, the reduction of the enzymatic activity of PARP is comparedto the activity level of PARP when activated by DNA damage (such as byDNA damaging chemotherapeutic agents like cisplatin, etoposide, or gammaradiation).

In embodiments, the PARP inhibitor compound modulates the tumormicroenvironment. For example the PARP inhibitor compound reduces theactivity of myeloid derived suppressor cells (MDSCs). In embodiments,the PARP inhibitor compound reduces the tumor suppressive activity ofMDSCs. Modulation of the tumor microenvironment can be measured by, forexample, assessment of immune cells within a biopsy (such as by FACSusing markers specific to MDSC, CD8, NK, DC).

In embodiments, the PARP inhibitor compound is administered as apharmaceutical composition. In some embodiments, the pharmaceuticalcomposition further comprises at least one additional anti-cancer agentand/or an anti-inflammatory agent. For example, the anti-cancer agentcan be an anti-cancer immunotherapy, such as an anti-PD1 antibody, ananti-CTLA4 antibody, an anti-PDL1 antibody, or other such checkpointblockade antibodies known in the art (e.g., Aris et al., (2017) FrontImmunol., 8: 1024; and Diesendruck et al., (2017) Drug Resist Updat.Jan;30:39-47, each of which are incorporated by reference in theirentireties). In other embodiments, the anti-cancer agent can be aninhibitor of indoleamine 2,3-dioxygenase-1 (i.e., IDO inhibitor). Forexample, the IDO inhibitor can be a small molecule inhibitor, such asEpacadostat, Indoximod, or Navoximod.

In embodiments, the PARP inhibitor compound is administered in a singledose.

In embodiments, the PARP inhibitor compound is administered at intervalsof about 4 hours, 12 hours, or 24 hours. In some embodiments, the PARPinhibitor compound is administered to the subject on a regular basis,for example three times a day, two times a day, once a day, every otherday or every 3 days. In other embodiments, the PARP inhibitor compoundis administered to the subject on an intermittent basis, for exampletwice a day followed by once a day followed by three times a day; or thefirst two days of every week; or the first, second and third day of aweek. In some embodiments, intermittent dosing is as effective asregular dosing.

In embodiments, the PARP inhibitor compound is administered orally,intraperitoneally, subcutaneously, intravenously, or intramuscularly.

Aspects of the invention are also drawn towards a dosing regime for thetreatment of cancer in a subject. For example, the dosing regimencomprises administering to a subject a metronomic dose of a PARPinhibitor compound. In other embodiments, the dosing regime furthercomprises administering therapeutically effective amount of at least oneadditional anti-cancer agent. For example, the metronomic dose of thePARP inhibitor compound comprises a dose that is below the establishedmaximum tolerated dose of the PARP inhibitor.

In embodiments, the PARP inhibitor compound is administered every otherday.

In embodiments, the at least one additional anti-cancer agent isadministered to the subject every four (4) days, every seven (7) days,every fourteen (14) days, every twenty-one (21) days, or everytwenty-eight (28) days. For example, the at least one additionalanti-cancer agent comprises a checkpoint blockade inhibitor, such asanti-PD1 or anti-CTLA4 antibody. In other embodiments, the anti-canceragent comprises an IDO inhibitor, such as Epacadostat, Indoximod, orNavoximod.

Other objects and advantages of this invention will become readilyapparent from the ensuing description.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 shows the partial PARP-1 inhibition is sufficient to blockexpression of inflammatory genes in LPS-treated colon epithelial cells.Primary colon epithelial cells were isolated from WT, PARP-1+/−, orPARP-1−/− mice. (A) Protein extracts were subjected to immunoblotanalysis with antibodies to PARP-1 or actin (Note that PARP-1+/−expressed ˜50% of PARP-1 shown in WT cells. (B) Cells were treated with2 mg/ml LPS. RNA was extracted then analyzed by real-time PCR. (C) Cellswere treated with 10 ng/ml TNF-α. Protein extracts were subjected toimmunoblot analysis with antibodies to COX-2, VCAM-1, or actin.

FIG. 2 shows partial PARP-1 inhibition by gene heterozygosity is moreefficient than complete inhibition by gene knockout at reducing chronicinflammation-driven colon tumorigenesis in an AOM/DSS mouse model ofcolon cancer. WT, PARP-1+/− or PARP-1−/− mice received a singleinjection of the carcinogen azoxymethane (AOM) followed by 4 bi-weeklycycles of DSS (inducer of chronic inflammation) and sacrificed at 16 wksof age. (A) Tumor numbers along the colon were assessed. (B) H&Estaining of tumors and immunohistochemical analysis with antibodies toPCNA, a marker of cell proliferation. (C) H&E staining showing theprotective effect of PARP-1 gene heterozygosity or knockout againstAOM/DSS-induced colitis.

FIG. 3 shows pharmacological inhibition of PARP by olaparib is veryeffective at reducing COX-2 partially reduces the tumor burden inAOM/DSS-treated WT mice. WT were treated with AOM and DSS as describedabove. Groups of mice were administered 5 mg/kg or 25 mg/kg olaparibtwice a week. Mice were sacrificed at 16 wks of age. (A) Tumor numberswere counted. (B) H&E staining showing the protective effect of PARP-1inhibition by olaparib against AOM/DSS-induced colitis.

FIG. 4 shows PARP-1 inhibition reduces systemic inflammation inAOM/DSS-treated mice. Sera from the different experimental groups andcontrols were assessed for IL-6, TNF-α, and MCP-1 by ELISA.

FIG. 5 shows partial inhibition of PARP-1 (by gene heterozygosity orolaparib) protects against, while complete inhibition (by gene knockout)aggravates, APC^(Min)-induced tumor burden in mice: No major connectionwith systemic inflammation. WT, PARP-1+/− or PARP-1−/− mice were bredinto an ApcMin background and sacrificed at 16 weeks of age. (A) Tumornumbers along the intestinal track were assessed. Note the opposingeffects of PARP-1 gene heterozygosity and knockout (B) Size of tumorswas assessed and classified as small (<2 mm), medium (2-4 mm), or large(>4 mm). (C) H&E staining of tumors and immunohistochemical analysiswith antibodies to PCNA, a marker of cell proliferation. (D) Five wk oldApcMin/+ mice were administered 5 mg/kg olaparib twice a week. Mice weresacrificed at 16 wks of age. Note the protective effect of olaparib. (E)Sera from the different experimental groups and controls were assessedfor IL-6, TNF-α, and MCP-1 by ELISA. Note that all forms of PARPinhibition reduced TNF-α and MCP-1 but not IL-6.

FIG. 6 shows PARP-1 inhibition provides a tumor-suppressive environmentand reduces splenomegaly in MCA-38 cell-based allograft(immunocompetent) model of colon cancer. The colon adenocarcinoma cellline derived from a C57BL/6 mouse were engrafted subcutaneously into WT,PARP-1+/− or PARP-1−/− mice. (A) Tumor sizes were measured at differentdays (15 and 21 days are shown). (B) actual tumors isolated from thedifferent mouse strains. Note that tumors developed in PARP-1+/− orPARP-1−/− mice were significantly smaller than those of WT mice.

FIG. 7 shows PARP-1 inhibition by gene heterozygosity or knockout blocksthe suppressive activity of MDSCs. Myeloid-derived suppressor cells(MDSCs) were isolated from tumors developed on WT, PARP-1+/− orPARP-1−/− mice. The MDSCs were then tested for their ability to suppressproliferation of CFSC-labeled WT T cells at a MDSC/T cell ratio of 8/1or 4/1. Note that both PARP-1+/− and PARP-1−/− MDSCs failed to suppressT cell proliferation albeit PARP-1−/− cells showed the leastsuppression.

FIG. 8 shows Olaparib (5 mg/kg) reduces the tumor burden of theAPCMin/+mice. Mice received i.p. injections of AZD2281 twice a week for11 weeks. The treatment was started at 5 weeks of age. Tumor burden wasassessed at 16 weeks of age.

FIG. 9 shows tumor burden in mice treated with Olaparib. Mice receivedan i.p. injection of 10 mg/kg of AOM at 8 weeks of age. A week later,they were given 1.25% of DSS in drinking water for a week followed bytwo weeks of regular water. This DSS regimen was repeated 4 times. Twogroups of WT received i.p. injections of AZD2281 twice a week at eitherlow dose of 5 mg/kg or high dose at 25 mg/kg. All mice were sacrificedat the end of 21 weeks and were subjected to colon tumor burden count.Note that the most effective protection against the tumor burden wasachieved by PARP-1 gene heterozygosity.

FIG. 10 shows Poly(ADP-ribose) polymerase-1 (PARP-1).

FIG. 11 shows exemplary processes in which PARP-1 is involved in. SeeCancers 2013, 5(3), 943-958.

FIG. 12 shows chemical structure of (A) Rubraca and (B) Olaparib.Rubraca comes in tablet formthe starting dose is two 300-mg tablets,taken orally twice a day, with or without food.

FIG. 13 shows the concept of synthetic lethality. Major issues with thestrategy include continuous use of high doses of the drug (such as aminimum of 600 mg/day), and development of resistance.

FIG. 14 shows partial PARP-1 inhibition is sufficient to blockexpression of inflammatory genes in primary colon epithelial cells. (A)Phase-contrast microscopy of a typical CEC colony emerging from a purecrypt (black arrow); the right panel is a higher magnification,demonstrating isolation of primary colon epithelial cells. (B) CECs wereisolated from WT, PARP-1^(+/−) or PARP-1^(−/−) mice. Protein extractedwere subjected to immunoblot analysis, demonstrating that geneheterozygosity reduces (only partially) expression of PARP-1, whileknockout eliminates the protein completely. (C and D) CECs were treatedwith LPS (2 μg/ml) for 6 h or TNF after which RNA was extracted; cDNAswere subjected to real-time PCR using set of primers for mouse TNF,IL-6, ICAM-1, VCAM-1 or β-actin. Fold changes (ΔΔCT values) were thencalculated using β-actin as a normalization control. *, p≤0.05; **,p≤0.01; ***, p≤0.001; ****, p≤0.0001, demonstrating that partialinhibition of PARP-1 by heterozygosity is sufficient to inhibitinflammation as shown by markers of inflammation such as TNF, andothers.

FIG. 15 shows partial inhibition of PARP-1 is more effective at reducinginflammation-driven colon tumorigenesis. WT, PARP-1^(+/−) orPARP-1^(−/−) mice received 10 mg/kg of AOM, i.p. once followed by 4cycles of 2.5% DSS in drinking water. (A) At 21 weeks of age, mice weresacrificed and colon tumor burden was counted. (B) H&E staining of colontumor sections. (C) IHC with an anti-PCNA antibody. (D) H&E stainingshowing the protective effective of PARP-1^(+/−) and PARP-1^(−/−)against AOM/DS S-induced colitis. (E) Sera were assessed for IL-6, TNFor MCP-1 using sandwich ELISA. *, p≤0.05; **, p≤0.01; ***, p≤0.001;****, p≤0.0001.

FIG. 16 shows involvement of immune cells in tumor microenvironment andtumorigenesis.

FIG. 17 shows PARP-1 inhibition by gene heterozygosity or knockoutblocks the suppressive activity of MDSCs

FIG. 18 shows PARP-1 inhibition does not interfere with T or dendriticcell function. Further, see J Immunol Jun. 15, 2006, 176 (12) 7301-7307.

FIG. 19 shows Low dose of a PARP inhibitor is as effective as a highdose in blocking colon cancer when administered at a very early stage

FIG. 20 shows Low dose of a PARP inhibitor is much more effective thanthe high dose in blocking colon cancer when administered after a cleardevelopment of tumors

FIG. 21 shows (A) A sample of genotyping: Bands representing WT APC orAPC^(Min) (top panel) or WT PARP-1 or KO (bottom panel). Genotype of themice is displayed below the panels. (B) Tumor numbers were counted at16-week-old of age in APC^(Min/+), APC^(Min/+)/PARP^(+/−), andAPC^(Min/+)/PARP-1^(−/−) mice (per group>10 mice). (C) Tumor burden wasanalyzed based on size and divided in groups lower than 2 mm, 2-4 mm,and tumors bigger than 4 mm. Colon tumor sections from were subjected toimmunohistochemistry (IHC) with antibodies specific to PCNA (D) or COX-2(E). *, p≤0.05; **, p≤0.01; ***, p≤0.001; ****, p≤0.0001.

FIG. 22 shows APC^(Min/+) mice were randomized into 3 groups andreceived, i.p., 5 mg/kg of olaparib (0.005% DMSO in saline), 25 mg/kg ofthe drug twice a week, or vehicle from 5 weeks up to 16 weeks of age.Mice were then sacrificed and tumor burden was quantified. (B) Weight ofmice from the different groups at 16 weeks of age. *, p≤0.05; **,p≤0.01; ***, p≤0.001.

FIG. 23 shows sera from the different mouse groups were assessed forIL-6, TNF or MCP-1 using sandwich ELISA according to manufacturer'sinstructions.

FIG. 24 shows (A) Protein extracts from MCA-38 cells, RAW264.7 cells, orcolon epithelial cells derived from WT, PARP-1^(+/−), or PARP-1^(−/−)mice were subjected to immunoblot analysis. MCA-38 cells (2.5×10⁵) wereinjected subcutaneously into the left flank of WT, PARP-1^(+/−), orPARP-1^(−/−) mice. (B) Tumor sizes were measured at day 15. (C) Imagesof two representative tumors isolated from the different groups. Bar=1cm. (D) Sera from the different mouse groups were assessed for TNF byELISA as above. Tissue sections from MCA-38-generated tumors weresubject to IHC with antibodies to ICAM-1(E) or CD68, a macrophage marker(F). For (B) and (D): *, p≤0.05; **, p≤0.01; ***, p≤0.001.

FIG. 25 shows (A) MDSCs derived from tumors of WT, PARP-1^(+/−) orPARP-1^(−/−) mice (n=4 for each group) were assessed for their abilityto suppress proliferation of CFSC-labeled WT T cells at a MDSC/T cellratio of 1:8. (B) Bone marrow (BM)-derived DCs were incubated withlOng/m1 GM-CSF for 8 days; some WT DCs were cultured in the presence of1 μM olaparib (spiked every 2 days). CD11c⁺ cells were co-cultured withCFSE-labeled CD4⁺ T cells from OTII mice. T cell proliferation wasassessed by FACS. *, p≤0.05; **, p≤0.01; ***, p≤0.001.

FIG. 26 shows A549 cells were subjected to knockdown using a lentiviralvector encoding a shRNA or to a CRISPR/Cas9 plasmid system (Santa Cruz)targeting PARP-1 and their respective controls. After selection, proteinextracts were subjected to immunoblot analysis with antibodies to PARP-1or actin.

FIG. 27 shows high PCNA immunoreactivity (a marker of cellproliferation) was detected in tumors of AOM/DSS-treated WT andPARP-1^(−/−) mice, which was much lower in tumors of treatedPARP-1^(+/−) mice (p<0.001).

FIG. 28 shows weight loss observed in the APC^(Min/+) mice was preventedby PARP-1 heterozygosity but not KO (FIG. 28).

FIG. 29 shows rrepresentative PCR products showing the genotype of thedifferent mouse strains.

FIG. 30 shows (A) primary macrophages were isolated from WT orPARP-1^(−/−) mice. Cells were then incubated either for 12 or 24 h inthe presence or absence of the indicated concentration of oxLDL. Proteinextracts were prepared from then collected cells the subjected toimmunoblot analysis with antibodies to CHOP or Actin. (B) RAW cells(mouse macrophage cell line) were treated with 10 mg/ml oxLDL for 6 h inthe presence or absence of 1 mM of the PARP inhibitor TIQ-A. Proteinextracts were prepared from the collected cells then subjected toimmunoblot analysis with antibodies to CHOP.

FIG. 31 shows that (A) PARP inhibition my also enhance the antitumoreffects of low dose of PARP inhibitor compared to higher dose, and that(B) this effect may be due to increased infiltration of cytotoxic CD8+T- cells in the tumor microenvironment.

FIG. 32 shows partial PARP-1 inhibition is sufficient to block chronicinflammation and associated colon tumorigenesis. (A) CECs were isolatedfrom WT, PARP-1^(+/−) or PARP-1^(−/−) mice. Total protein extracts weresubjected to immunoblot analysis with antibodies to PARP-1 or actin. (B)CECs were treated with 2 μg/ml LPS or 10 ng/ml TNF-α for 6 h after whichRNA was extracted; cDNAs were subjected to real-time PCR using sets ofprimers for mouse TNF-α, IL-6, ICAM-1 or β-actin. Fold changes (ΔΔCTvalues) were then calculated using β-actin as a normalization control.(C) WT, PARP-1^(+/−) and PARP-1^(−/−) mice received 10 mg/kg of AOM,i.p. once followed by 4 cycles of 1.25% DSS in drinking water. At 21weeks of age, mice were sacrificed and colon tumor burden was assessed.(D) H&E staining of colon tumor sections from the different experimentalgroups. (E) IHC with antibodies to PCNA. (F) H&E staining showing theprotective effect of PARP-1 gene heterozygosity and knockout againstAOM/DSS-induced colitis. (G) WT mice were subjected to AOM/DSS protocolas described above. Mice from all experimental groups received i.pinjections of 5 or 25 mg/kg olaparib or a vehicle twice a weekimmediately after AOM administration and until a day prior to sacrifice(21 weeks). Colon tumor numbers were counted. (H) H&E staining showingthe protective effect of PARP-1 inhibition by olaparib againstAOM/DSS-induced colitis. (I) Sera from the different experimental groupswere assessed for IL-6, TNF-α or MCP-1 using sandwich ELISA. For (B),(C), (G), and (I), *, p≤0.05; **, p≤0.01; ***, p≤0.001; ****, p≤0.0001.Bar=50 μm.

FIG. 33 shows partial inhibition of PARP-1 protects, while completeinhibition is ineffective, against APC^(Min)-induced tumor burden inmice. (A) APC^(Min/+), APC^(Min/+) PARP -1^(+/−), and APC^(Min/+)PARP-1^(−/−) mice (per group>10 mice) were sacrificed at 16 weeks ofage. Tumor numbers were then counted. (B) Tumor burden was analyzedbased on size and divided in groups lower than 2 mm, 2-4 mm, and tumorsbigger than 4 mm. Colon tumor sections from the 3 different groups weresubjected to immunohistochemistry (IHC) with antibodies specific to PCNA(C) or COX-2 (D). (E) APC^(Min/+) mice were randomized into 3 groups andreceived, i.p., 5 or 25 mg/kg olaparib twice a week, or vehicle (0.005%DMSO in saline) from 5 weeks up to 16 weeks of age. Mice were thensacrificed and tumor burden was quantified. Total body (F) or spleen (G)weight of mice from the different groups at 16 weeks of age. (F) Serafrom the different mouse groups were assessed for TNF-α, IL-6, or MCP-1using sandwich ELISA. For (A), (B), (E-H), *, p≤0.05; **, p≤0.01; ***,p≤0.001; ****, p≤0.0001. *, p≤0.05; **, p≤0.01; ***, p≤0.001. Bar=50 μm.

FIG. 34 shows a metronomic dose of olaparib or PARP-1 heterozygosity aresufficient to promote a tumor-suppressive environment in a syngeneiccolon cancer mouse model. (A) Protein extracts from MC-38 cells,RAW264.7 cells, or mouse embryonic fibroblasts derived from WT,PARP-1^(+/−), or PARP-1^(−/−) mice were subjected to immunoblotanalysis. (B) MC-38 cells (2.5×10⁵) were injected s. c. into the leftflanks of WT, PARP-1^(+/−) or PARP-1^(−/−) mice. Tumor sizes weremeasured at day 21. (C) Mice were sacrificed and tumor sections weresubjected to H&E (left panels) or IHC straining (right panels) withantibodies to ICAM-1. (D) Spleen weight of mice from the differentgroups. (E) MC-38 cells were engrafted onto WT mice. When tumors becamepalpable (day 4-6), mice received different doses of olaparib orvehicle. Tumor volume was measured at the indicated days. (F) Mice weresacrificed at day 24 and tumor sections were subjected to IHC strainingwith antibodies to ICAM-1. (G) Sera from the different mouse groups wereassessed for TNF-α, IL-6 or MCP-1 by ELISA. (H) Protein extracts fromtumors derived from the different experimental groups were subjected toimmunoblot analysis with antibodies to cleaved (active) caspase-3,caspase-7 or H3 as a loading control. For (B), (D-E), and (G): p≤0.05;**, p≤0.01; ***, p≤0.001. Bar=50 μm.

FIG. 35 shows the suppressive function of MDSCs is highly sensitive toPARP inhibition. Tumors from the different experimental groups wereeither processed to generate single-cell suspensions or fixed withformalin. Single cell suspensions were stained with a combination ofantibodies to CD45, CD11b, Gr1, Ly6C, and Ly6G. CD11b⁺ cell populationwas gated from the live CD45⁺ population. (A) Representative FACS dotplot of the experimental groups. (B) Absolute numbers and percentages ofCD11b⁺Gr1⁺ cell populations in tumors of the different groups. (C)Absolute numbers and percentages of CD11b⁺Ly6C⁺ and CD11b⁺Ly6G⁺populations in tumors of the different groups. (D) Absolute numbers andpercentages of CD45⁺CD3⁺ and CD3⁺CD8⁺ cell populations in tumors of thedifferent groups. (E) Serial sections of tumors from WT mice that weretreated with 0.2 or 5 mg/kg olaparib or vehicle or PARP-1^(+/−) micewere subjected to IHC (left panels) or immunofluorescence (right panels)with antibodies to mouse Gr1 or CD8. (F) Percentages of CD45⁺CD3⁺ andCD3⁺CD8⁺ cell populations in spleens of the different groups. (G)CD11b⁺-enriched MDSCs isolated from tumors of WT mice that were treatedwith 0.2 or 5 mg/kg olaparib or vehicle or PARP-1^(+/−) mice wereassessed for their ability to suppress proliferation ofCD3/CD28-stimulated and CFSC-labeled WT CD3⁺ T cells at a MDSC/T cellratio of 1:8. T cell proliferation was assessed by FACS. p≤0.05; **,p≤0.01; ***, p≤0.001.

FIG. 36 shows a sub-IC50 concentration of olaparib is sufficient tointerfere with MDSC suppressive function by blocking expression ofARG-1, iNOS, and COX2 and adoptive transfer of WT MDSCs abrogates theprotective effects of PARP-1 heterozygosity against the tumor burdenBone marrow progenitors derived from WT or PARP-1^(+/−) mice wereincubated with a cocktail of GM-CSF, G-CSF, and IL-6 at day 0. After 24h, WT cells were treated with different concentrations of olaparib orDMSO. After 96 h, cells were collected and stained with antibodies toCD11b or Gr1 and assessed by FACS (A) or co-cultured withCD3/CD28-stimulated and CFSC-labeled WT CD3⁺ T cells for 72 h followedby an assessment of proliferation by FACS (B). (C) A portion ofCD3/CD28-stimulated and CFSE-labeled WT T cells were incubated withdifferent concentrations of olaparib in the absence of MDSCs for 72 hand assessed for proliferation by FACS. (D) An equal number of MCA-38cells were engrafted onto the left flanks of WT or PARP-1^(+/−) mice. Atdays 8 and 16, mice received, intratumorally, 3×10⁶WT BM-MDSCs orvehicle. Tumor sizes were measured at the indicated days. (E) Bonemarrow cells were stimulated and treated with 4 nM or 5 μM olaparib asin (A). Cells were collected at days 2, 3 or 4. Total protein extractswere prepared and subjected to immunoblot analysis with antibodies toARG-1, iNOS, COX-2, PARP-1, p53, phospho(S15)-p53, phospho(S37)-p53,STAT3, phospho(Y705)-STAT3, GAPDH, or Actin. (F) Bone marrow cells werestimulated with the cytokine cocktail in the presence of 4 nM or 1 μMolaparib as in (A). At day 4 of MDSC differentiation (70% Gr1⁺), wellsreceived 0.5 ml of fresh medium or medium containing MC-38 cells at aratio of 2:1 (MC-38/MDSC). The cells received a second treatment witholaparib but with no additional cytokines. Some MC-38 cells wereincubated without MDSCs and in the presence or absence of olaparib.Cells were collected after 2 days of treatment and protein extracts weresubjected to immunoblot analysis with antibodies to ARG-1, iNOS, PARP-1,tubulin or actin. (G) WT or PARP-1^(+/−) MDSCs were treated as in (F)except that 3LL cells were used instead of MC-38 cells. Protein extractswere subjected to immunoblot analysis with antibodies to iNOS or GAPDH.The modulatory effect of low-dose olaparib on MDSC function isindependent of PARP-1 trapping to chromatin (H) Bone marrow-derivedMDSCs were treated with different concentrations of olaparib for 12 h.Nuclear and chromatin fractions were prepared and subjected toimmunoblot analysis with antibodies to PARP-1 or H3. (I) Positivecontrol for PARP-1 trapping. Jurkat T cells were treated with 20 μMVP-16 in the presence or absence of 4 nM or 1 μM olaparib for 1 h.Chromatin fractions were subjected to immunoblot analysis withantibodies to PARP-1, γH2AX, or H3.

FIG. 37 shows synergy between a metronomic dose of olaparib and anti-PD1therapy to eradicate MC-38 cell-based tumors in mice. (A) MC-38 cellswere engrafted onto flanks of WT mice. When tumors became palpable (day4-6) mice were treated with 0.2 mg/kg olaparib, 100 μg anti-PD1, or acombination of the two agents; mice treated with only olaparib alsoreceived equal amount of IgG isotype (for example, clone 2A3 (cat#:BE0089 from bioxcell). Tumor volumes were then measured every 4 days.(B-C) GFP-Luciferase-expressing MC-38 cells were engrafted onto WT miceas in (A). At day 16, tumors were imaged by the whole body IVIS opticalimaging system (B) Representative images of the different experimentalgroups. (C) Bioluminescence in the region of interest (ROI) wasquantified in photons/sec/cm²/sr. (D) MC-38 cells were engrafted ontoflanks of WT or PARP-1^(+/−) mice. At day 6, mice were then administeredeither anti-PD1 or IgG isotype. Tumor volume was assessed at day 24. (E)Spleen weight of mice from the different groups. (F) Sera from thedifferent mouse groups were assessed for TNF-α, IL-6, or MCP-1 by ELISA.(G) Protein extracts from tumors derived from the different experimentalgroups were subjected to immunoblot analysis with antibodies to PD-L1,cleaved (active) caspase-3, -7, -8, or -9, γH2AX, GAPDH, p21/Waf1/Cip1,poly(ADP-ribose) (PAR), cleaved PARP-1 (p85), or Grb2. Two left bracesrepresent two different gels using the same samples. (H) CT-26 cellswere engrafted onto flanks of WT mice and then treated with olaparibwith anti-PD1 or IgG isotype as described in (A). Tumor volumes werethen measured every 4 days. (I) Spleen weight of mice from the differentgroups. For (A), (C-F), and (H-I), *, p≤0.05; **, p≤0.01; ***, p≤0.001.

FIG. 38 shows quantification of PCNA positive cells in the colonicmucosa of AOM/DSS-treated mice. Data is expressed as percent of totalcells per 10 mm2 area within colonic mucosa. *, p≤0.05; ***, p≤0.001.

FIG. 39 shows genotyping of APC^(Min/+) APC^(Min/+) PARP-1^(+/−), andAPC^(Min/+) PARP-1^(−/−) mice. Experimental groups of APCMin/+mice areshowing in the top panel, while the Bottom panel represents thegenotyping of PARP-1 in each experimental group. (B) Tumor numbers alongintestinal tract were counted in.

FIG. 40 shows PARP-1 gene knockout blocks the suppressive activity ofMDSCs. CD11b-enriched MDSCs isolated from tumors of WT, PARP-1+/− orPARP-1−/− mice were assessed for their ability to suppress proliferationof CD3/CD28-stimulated and CFSC-labeled WT CD3+ T cells at a MDSC/T cellratio of 1:8. T cell proliferation was assessed by FACS. * , p≤0.05; **,p≤0.01; ***, p≤0.001.

FIG. 41 shows effects of PARP inhibition on viability anddifferentiation of bone marrow-derived MDSCs in vitro. WT, treated withdifferent concentrations of olaparib, PARP-1+/− or PARP-1−/− mice werestimulated with GM-CSF, G-CSF, and IL-6 as described for FIG. 5A. (A)Viability of differentiated cells was assessed by FACS. Only the 5 μMolaparib caused a slight but statistically significant decrease inpercentage of viable cells. (B) PARP inhibition by 5 μM olaparib in WTcells or PARP-1 knockout increased percentage of Gr1+ MDSCs. * , p≤0.05;**, p≤0.01

FIG. 42 shows PARP-1 gene knockout increases prevalence of Gr⁺-MDSCs inAPC^(Min/+) mice. Tissue sections from the different experimental groupswere subjected to IHC or immunofluorescence with antibodies to mouse Gr1or CD8. The assessment of Gr1+ cells was conducted, in a blinded manner,by Dr L. DelValle.

FIG. 43 shows differential effects of low and high concentrations ofolaparib on PD-L1 expression in MDSCs co-cultured with MC-38 cells. Bonemarrow-derived MDSCs were co-cultured with MC-38 cells and treated witholaparib as described for FIG. 36E. The same blot was assessed for PD-L1using antibodies to mouse PD-L1. Note that the blot for tubulin andactin is the same as the one displayed in FIG. 36E.

FIG. 44 shows effect of olaparib, anti-PD1, or combination treatment onprevalence of MDSCs in CT-26 cell-based tumors in mice.

FIG. 45 shows detailed description of the gating strategy used to assessMDSCs in the different experimental groups.

FIG. 46 shows synergy between a metronomic dose of olaparib andanti-CTLA4 therapy to eradicate MC-38 cell-based tumors in mice. (A)MC-38 cells were engrafted onto flanks of WT mice. When tumors becamepalpable, mice were treated with 0.2 mg/kg olaparib, 100 mg anti-CTLA4,or a combination of the two agents; mice treated with only olaparib alsoreceived equal amount of IgG isotype. Tumor volumes were then measured.Tumors from the different experimental groups were processed to generatesingle-cell suspensions, which were stained with a combination ofantibodies to CD45, CD11 b, Gr1, Ly6C, Ly6G, CD3, CD4, or CD8. CD11 b⁺cell population was gated from the live CD45⁺ population. (B)Percentages of CD45⁺CD3⁺ and CD3⁺CD8⁺ cell populations in tumors of thedifferent groups. (C) Percentages of CD11b⁺Gr1⁺ and those of CD11b⁺Ly6C⁺and CD11b⁺Ly6G⁺ populations in tumors of the different groups. *,p≤0.05; **, p≤0.01; ***, p≤0.001.

FIG. 47 shows a low of olaparib enhances while a high concentrationdecreases T cell function in vitro. CD3⁺ T cells were isolated fromspleen then stimulated with antibodies to CD3 and CD28 for 3 days.Protein extracts were analyzed by immunoblotting with antibodies toperforin (a marker of T cell function) or GAPDH. Note that the 4 nMconcentration increased, while the 1mM decreased, perforin levels.

FIG. 48 shows different PARP inhibitors reduce MDSC function (A) Bonemarrow-derived MDSCs were incubated at day 2 of differentiation withDMSO or the different PARP inhibitors at the indicated concentrations.At day 4, a portion of the cells was assessed for CD11b and Gr1 by FACS.** p≤0.01. (B) Proteins from the remaining cells were subjected toimmunoblot analysis with antibodies to Argl or Grb2 (as a loadingcontrol). This figure shows that none of the PARP ihibitors affectedMDSC phenotype (CD11b⁺/Gr1⁺) at day 4 of differentiation exceptrucaparib at 1 μM, which appears to increase MDSC population.Consistently with our results, a low concentration of 4 nM of rucaparib,niraparib, or velaparib or 0.4 nM talazoparib blocked expression of Arg1in BM-MDSCs in a manner similar to olaparib.

FIG. 49 shows bone marrow cells isolated from Wild type or PARP-1+/−(heterozygous) mice were induced for differentiation into MDSCs with40ng/m1 GM-CSF, G-CSF, and IL-6. Wild type cells were treated witheither 4 nM (4n) or 1mM (1u) olaparib. Cells were collected at theindicated time intervals. Protein extracts were prepared and subjectedto immunoblot analysis with antibodies to the factors mentioned in theside of each gel. Gel 1, 2, and 3 were generated using the same samples.

FIG. 50 shows ultra-low doses of olaparib (AZD2281) reverse steroidresistance in KOPT-K1 cells. Kopt-K1, a steroid-resistant leukemia cellline was treated with different concentrations of dexamethasone (Dex) inthe absence or the presence of different concentrations of AZD2281(Olaparib)/AZD(in figure). Cell viability was assessed 2.5 days aftertreatment by Trypan exclusion assay. Statistics are not included.

FIG. 51 shows ultra-low doses of olaparib (AZD2281) reverse steroidresistance in KOPT-K1 cells. Kopt-K1 cells were treated with differentconcentrations of dexamethasone in the absence or the presence ofdifferent concentrations of AZD2281 (Olaparib). Cell viability wasassessed 2.5 days after treatment by Trypan exclusion assay. Statisticsare not included.

FIG. 52 shows ultra-low doses of olaparib (AZD2281) synergize withsteroids in KOPT-K1 cells to promote the complete disappearance ofNOTCH1 and NOTCH3 in addition to several related proteins. Kopt-K1 cellswere treated with different concentrations of dexamethasone in theabsence or the presence of different concentrations of AZD2281(Olaparib). Protein extracts were collected 2.5 days after treatment.Proteins were analyzed with immunoblot analysis using antibodies tooncogenic (active) NOTCH1, NOTCH3, HES1, Hsp90, glucocorticoid receptor(GR), Rnd3, p105-NF-κB, p50 NF-κB, Spl, caspase-3 (full length or itsactive form), Pin1, or GAPDH. Bands were visualized using ECL fromPierce.

FIG. 53 shows ultra-low doses of olaparib synergizes with steroids topromote degradation of NOTCH1 in the steroid resistant leukemia cellline Jurkat. Jurkat cells were treated with 0.5 μM dexamethasone in theabsence or the presence of different concentrations of AZD2281(Olaparib). Protein extracts were collected 2.5 days after treatment.Proteins were analyzed with immunoblot analysis using antibodies toNOTCH1. Bands were visualized using ECL from Pierce.

FIG. 54 shows ultra-low doses of olaparib (AZD2281) synergize withestablished γ-secretase inhibitors (tested in clinical trials). Kopt-K1cells were treated with 0.5 μM dexamethasone (Dex) in the absence or thepresence of different drugs 4 nM AZD2281 (Olaparib); 1 nM PF-03084014(PF); 25 nM BMS-906024 (BMS). Protein extracts were collected 2.5 daysafter treatment. Proteins were analyzed with immunoblot analysis usingantibodies for the indicated proteins. FL: full length protein. Bandswere visualized using ECL from Pierce.

FIG. 55 shows reproducibility of the effects of the different drugcombination on active NOTCH1 and HES1 in Jurkat T cells. Jurkat cellswere treated with 0.5 μM dexamethasone (Dex) in the absence or thepresence of different drugs: 4 nM AZD2281 (Olaparib); 1 nM PF-03084014(PF); 25 nM BMS-906024 (BMS). Protein extracts were collected 2.5 daysafter treatment. Proteins were analyzed with immunoblot analysis usingantibodies for the indicated proteins. Bands were visualized using ECLfrom Pierce.

FIG. 56 shows reproducibility of the effects of the different drugcombination on cell killing in the steroid-resistant cell line T-ALL1.The steroid-resistant leukemia cell line T-ALL-1 was treated with 0.5 μMdexamethasone in the absence or the presence of 4 nM AZD2281 (Olaparib).Cells were also treated with the γ-secretase inhibitors (1 nMPF-03084014 or 25 nM BMS-906024). Cell viability was assessed 2 daysafter treatment by Trypan exclusion assay. Statistics are not included.

FIG. 57 shows combination of dexamethasone and olaparib does not causemajor cell killin in normal human PBMCs (peripheral blood mononucleatedcells). PBMCs isolated from healthy volunteers were stimulated withanti-CD3/CD28 antibodies in the presence of the indicated combination ofdexamethasone and/or AZD2281 (Olaparib). Cell viability was assessed 2days after treatment by Trypan exclusion assay. Statistics are notincluded.

FIG. 58 shows the steroid-resistant leukemia cell line T-ALL-1 wastreated with 0.5 μM dexamethasone in the absence or the presence of 4 nMAZD2281 (Olaparib). Cells were also treated with the γ-secretaseinhibitors (1 nM PF-03084014 or 25 nM BMS-906024). Cell viability wasassessed 2 days after treatment by Trypan exclusion assay. Statisticsare not included.

FIG. 59 shows PARP inhibition increases phosphorylation ofglucocorticoid receptor in a lung epithelial cell line. The lungepithelial cell line A549 that expresses full or partial amounts ofPARP-1 was treated with different concentrations of dexamethasone (withor without IL-4) for 1 h. Protein extracts were collected 2.5 days aftertreatment. Proteins were analyzed with immunoblot analysis usingantibodies for the indicated proteins. Bands were visualized using ECLfrom Pierce.

FIG. 60 shows PARP inhibition restores sensitivity to dexamethasone andreduce airway hyperresponsiveness in mouse model of steroid resistantasthma. Balb/c mice were sensitized by i.p. injection of 20 μg of Ova in2.25 mg aluminium hydroxide on days 1 and 14. Steroid resistance wasinduced by intranasal instillation of Lps (10 μg/mouse) on day 27. Micewere treated with s.c injection of dexmethasone (5 mg/kg) on days 29 and30. Mice were challenged with aerosolized 1% OVA on days 28, 29, 30 for20 minutes. Airway hyper responsiveness was measured usingplesthesmography 24 hours after the last OVA challenge. Statistics arenot included.

FIG. 61 shows PARP inhibition restores sensitivity to dexamethasone andblock recruitment of inflammatory cells to the lung in in vivo steroidresistant asthma model. Balb I c mice were sensitized by i.p. injectionof 20 μg of Ova in 2.25 mg aluminium hydroxide on days 1 and 14. Steroidresistance was induced by intranasal instillation of Lps (10 □g/mouse)on day 27. Mice were treated with s.c injection of dexmethasone (5mg/kg) on days 29 and 30. Mice were challenged with aerosolized 1% OVAon days 28, 29, 30 for 20 minutes. All mice were euthanized 48 hoursafter the last OVA challenge then subjected to broncholaveolar lavage.Inflammatory cells were differentiated and assessed using Diff Quickstaining. Statistics are not included.

FIG. 62 shows PARP inhibition restores sensitivity to dexamethasone andblock IgE secretion and the Th2 cytokine production in in vivo steroidresistant asthma model. Balb/c mice were sensitized by i.p. injection of20 μg of Ova in 2.25 mg aluminium hydroxide on days 1 and 14. Steroidresistance was induced by intranasal instillation of Lps (10 μg/mouse)on day 27. Mice were treated with s.c injection of dexmethasone (5mg/kg) on days 29 and 30. Mice were challenged with aerosolized 1% OVAon days 28, 29, 30 for 20 minutes. All mice were euthanized 48 hoursafter the last OVA challenge. Cytokines were measured in the collectedserum and BAL fluid using multiplex assay. And IgE production wasassessed busing sandwich ELISA. Statistics are not included.

DETAILED DESCRIPTION OF THE INVENTION

Detailed descriptions of one or more preferred embodiments ofcompositions and methods for treating tumors comprising administeringPARP inhibitor compounds are provided herein.

It is to be understood, however, that the present invention may beembodied in various forms. Therefore, specific details disclosed hereinare not to be interpreted as limiting, but rather as a basis for theclaims and as a representative basis for teaching one skilled in the artto employ the present invention in any appropriate manner.

The singular forms “a”, “an” and “the” include plural reference unlessthe context clearly dictates otherwise. The use of the word “a” or “an”when used in conjunction with the term “comprising” in the claims and/orthe specification may mean “one,” but it is also consistent with themeaning of “one or more,” “at least one,” and “one or more than one.”

Wherever any of the phrases “for example,” “such as,” “including” andthe like are used herein, the phrase “and without limitation” isunderstood to follow unless explicitly stated otherwise. Similarly “anexample,” “exemplary” and the like are understood to be nonlimiting.

The term “substantially” allows for deviations from the descriptor thatdo not negatively impact the intended purpose. Descriptive terms areunderstood to be modified by the term “substantially” even if the word“substantially” is not explicitly recited.

The terms “comprising” and “including” and “having” and “involving” (andsimilarly “comprises”, “includes,” “has,” and “involves”) and the likeare used interchangeably and have the same meaning. Specifically, eachof the terms is defined consistent with the common United States patentlaw definition of “comprising” and is therefore interpreted to be anopen term meaning “at least the following,” and is also interpreted notto exclude additional features, limitations, aspects, etc. Thus, forexample, “a process involving steps a, b, and c” means that the processincludes at least steps a, b and c. Wherever the terms “a” or “an” areused, “one or more” is understood, unless such interpretation isnonsensical in context.

As used herein, the term “about” can refer to approximately, roughly,around, or in the region of When the term “about” is used in conjunctionwith a numerical range, it modifies that range by extending theboundaries above and below the numerical values set forth. The term“about” is used herein to modify a numerical value above and below thestated value by a variance of 20 percent up or down (higher or lower).

“Amelioration” can refer to any lessening of severity, delay in onset,slowing of growth, slowing of metastasis, or shortening of duration of atumor or cancer, whether permanent or temporary, lasting or transientthat can be attributed to or associated with administration of aPARPinhibitor compound or composition.

The terms “individual”, “patient” and “subject” can be usedinterchangeably. They refer to a mammal (e.g., a human) which is theobject of treatment, or observation. Typical subjects to which PARPinhibitor compounds can be administered will be mammals, particularlyprimates, especially humans. For veterinary applications, a wide varietyof subjects will be suitable, e.g., livestock such as cattle, sheep,goats, cows, swine, and the like; poultry such as chickens, ducks,geese, turkeys, and the like; and domesticated animals particularly petssuch as dogs and cats. For diagnostic or research applications, a widevariety of mammals will be suitable subjects, including rodents (e.g.,mice, rats, hamsters), rabbits, primates, and swine such as inbred pigsand the like.

Partial Inhibition of Poly(ADP-Ribose) Polymerase) for the Treatment ofDisease

Poly(ADP-ribose)polymerases (PARPs) is a family of proteins that play arole not only in DNA repair, but also in fundamental cellular processessuch as chromatin remodeling, transcription, and regulation of the cellcycle. PARPs interact with various cellular proteins and transcriptionfactors, including those that aid inflammation. Various studies haveshown that DNA damage occurs during inflammatory conditions, and thatPARPS (for example, PARP-1) participate in inflammation through theresponse to DNA damage. In fact, DNA damage that occurs duringinflammation leads to an over activation of PARPs (Deslee G, et al.Chest (2009) 135:965-74; Althaus FR, et al. Mol Cell Biochem (1999)193:5-11; Pereira C, et al. Inflamm Bowel Dis (2015) 21:2403-17;Palmai-Pallag T, et al. Microbes Infect (2014) 16:822-32) which canresult in an energy crisis due to depletion of their substrate, i.e.,nicotinamide adenine dinucleotide (NAD+), thus leading to non-specificcell death (i.e., necrosis) (Ha HC, Snyder SH. Proc Natl Acad Sci USA(1999) 96:13978-82.).

Mammalian PARP-1 is a 116-kDa protein which comprises of an N-terminalDNA-binding domain, a nuclear localization sequence (NLS), a centralautomodification domain, and a C-terminal catalytic domain (Luo X, etal. Genes Dev (2012) 26:417-32). The C-terminal region is the mostconserved part of the PARP family of proteins, and executes itscatalytic function. Specifically, the C-terminal region synthesizespoly(ADP)ribose (PAR) using NAD+ as a substrate (35, 36) and transfersthe PAR moieties to several proteins, including histones, DNA repairproteins, and transcription factors (Ame JC, et al. Bioessays (2004)26:882-93; Schreiber V, et al. Nat Rev Mol Cell Biol (2006) 7:517-28),ultimately altering the structure and functions of the acceptorproteins. Target proteins comprise, for example, a PARP protein itself(for example automodification of PARP-1′s BRCT (Breast CancerCarboxy-Terminal) domain), or modification of other proteins (i.e.,heteromodification) such as Histone H1, H2B, DNA pol a, topoisomerase I,II, lamin B, XRCC1, SV40 T-Ag, DNAS1L3; DFF40; p65 NF-kB, and/or STAT6.Under genotoxic stress conditions, PARP-1 binds itself to thenucleosomes containing intact (Kim M Y, et al. Cell (2004) 119:803-14)as well as damaged DNA structures (e.g., nicks and double-strand breaks)which leads to the activation of DNA repair enzymes (D′Amours D, et al.Biochem J (1999) 342(Pt 2): 249-68).

The covalently attached PAR can be hydrolyzed to free PAR ormono(ADP-ribose) by PAR glycohydrolase (PARG) (Min W, et al. FrontBiosci (Landmark Ed) (2009) 14:1619-26). Synthesis and degradation ofPAR chains is tightly controlled in vivo and PAR residues have a veryshort half-life in the cell (few minutes) (Luo X, et al. Genes Dev(2012) 26:417-32). Free or protein-bound PAR polymers also work assignal transducers by binding other proteins.

PARP-1 gets activated in response to DNA damage induced by ROS/RNS underinflammatory conditions (Ba X, et al. Am J Pathol (2011) 178:946-55,Pacher P, et al. Am J Pathol (2008) 173:2-13.). Although, the primaryaim of PARP-1 is to maintain the genome integrity, its over activationunder extensive and persistent DNA damaging environment promoteinflammatory conditions. Over activation of PARP-1 depletes itssubstrate, i.e., NAD+, bringing the cell to an energy deficient state,thus leading to necrosis (Islam BU, et al. Indian J Clin Biochem (2015)30:368-85). Recently, PARP-1 has been reported to cause cell death bysuppressing the activity of hexokinase-1 (an essential enzyme ofglycolysis) by adding PAR chains (Fouquerel E, et al. Cell Rep (2014)8:1819-31). Apart from inducing cellular death, PARP-1 promotesinflammation by influencing chromatin remodeling and expression ofseveral pro-inflammatory factors. Since the DNA is negatively charged,poly(ADP)ribosylation (also negatively charged) of histones results inrelaxing of nucleosomal structures and, hence, aids the transcription ofpro-inflammatory genes (Martinez-Zamudio R, et al. Mol Cell Biol (2012)32:2490-502, Martinez-Zamudio RI, et al. Brain Behav (2014) 4:552-65).PARP-1 regulates the expression of several NF-κB-dependent cytokines,chemokines, adhesion molecules, inducible nitric-oxide synthase (iNOS),required for the manifestation of inflammatory cycle (Naura AS, et al.Eur Respir J (2009) 33:252-62; Chiang J, et al. Eur J Pharmacol (2009)610:119-27; von Lukowicz T, et al. Cardiovasc Res (2008) 78:158-66; ParkEM, et al. Stroke (2004) 35:2896-901; Zingarelli B, et al. Circ Res(1998) 83:85-94; Sharp C, et al. Inflammation (2001) 25:157-63; UllrichO, et al. Nat Cell Biol (2001) 3:1035-42). PARP-1 gene deletion or itspharmacological inhibition results in suppressed migration of leukocytesto the inflammatory sites (Rosado MM, et al. Immunology (2013)139:428-37). Overall, studies demonstrate that PARP-1 plays apro-inflammatory role by inducing cellular death and upregulating theexpression of various inflammatory genes, via interaction with NF-κB(Zerfaoui M, et al. J Immunol (2010) 185:1894-902; Hassa P O, Cell MolLife Sci (2002) 59:1534-53). Further, see Sethi GS et al. Front.Immunol. (2017) 8:1172).

Poly(ADP-ribose) polymerase (PARP-1) is a nuclear enzyme that polymerizeadenosine diphosphate ribose on substrate proteins to regulate variousprocesses. See FIG. 11, for example. The function of PARP-1 in cancersmay be intimately related to its role in providing alternative andefficient pathways to cancer cells to survive especially for thoseassociated with defects in DNA repair (e.g. triple negative breast andovarian cancers). The role of PARP-1 in DNA repair requires fullactivity of the enzyme as partial inhibition of PARP-1 has not beenassociated with obvious defects in DNA repair. Achieving maximuminhibition of PARP-1 to treat cancers with DNA repair deficiency (e.g.breast or ovarian cancers with mutations in BRCA1 gene) is critical toinduce synthetic lethality of cancer cells. As discussed herein, thefocus on achieving maximal or about maximal inhibition of PARP maycontribute to the failure of two recent clinical trials using thePARP-1-inhibitor, olaparib (Lynparza™), on patients with advanced coloncancer as a monotherapy or in combination with irinotecan (Camptosar™),a topoisomerase I inhibitor. Achieving maximum inhibition of PARP totreat cancers with DNA repair deficiency (e.g. breast or ovarian cancerswith mutations in BRCA1 gene) is critical to induce synthetic lethalityof such cancer cells. However, partial inhibition may be the bestapproach to blocking inflammation-driven cancer or certain mutationdriven cancers, such as APC mutation-driven (e.g. FAP) colon cancer.

Without wishing to be bound by theory, DNA repair enzymes such as PARP-1play important roles in not only cancer-related processes but also inthe pathogenesis of many inflammatory diseases. However, it's role ininflammation may be very different than that in cancer. PARP-1 has acritical role during inflammation, in part, through its relationshipwith NF-kB, and embodiments as described herein demonstrate the roles ofPARP-1 in colon inflammation and cancer and their relationship. Examplesdescribed herein demonstrate the clinically relevant role of partialinhibition of a PARP enzyme, such as PARP-1, by using chemicalinhibitors of PARP, while also taking advantage of the fact that PARP-1gene heterozygosity reduces expression and activity of PARP-1 by about50%. As an example of a clinically relevant PARP inhibitor, examplesdescribed herein utilize olaparib (AZD2281)), a potent inhibitor ofPARP-1, PARP-2, and PARP-3 that is used in the clinic as a monotherapyfor triple-negative ovarian cancer. Triple negative ovarian cancer isdefined based on negative oestrogen receptor (ER), progesterone receptor(PR) and human epidermal growth factor receptor-type 2 (HER2)expression. Experiments described herein also use the extensivelystudied APC^(Min/+) mouse model of intestinal cancer, which is astandard model for spontaneous tumorigenesis. In this model, aberrantWnt/β-catenin signaling following loss of the tumor suppressor gene,adenomatous polyposis coli (APC), is thought to initiate colon adenomaformation. Still further, experiments described herein also use thecarcinogen/inflammation colon cancer model (azoxymethane+DSS-driven). Inthis model, DSS regimen is given to induce chronic relapsinginflammation after the potentiation by the carcinogen, azoxymethane(AOM), in colon. Finally, a MCA-38 colon carcinoma cell-based allograftmodel was used in examples described herein, which allows for theinvestigation of the host environment response to tumor growth.

Referring to the Examples, partial PARP-1 inhibition (50%) was veryeffective at reducing or even blocking expression of inflammatory genesin response to LPS or TNF-α treatment and that complete inhibition ofthe enzyme was not necessary to achieve maximal effects. See FIG. 14,for example. This appears to be due, in part, to a reduction inNF-κB-signal transduction. The remarkable anti-inflammatory effects ofPARP-1 inhibition (partial or total) can be protective against chronicinflammation-driven colon carcinogenesis. Surprisingly, partial PARP-1inhibition by gene heterozygosity was more efficient than completeinhibition by gene knockout at reducing chronic inflammation-drivencolon tumorigenesis using an azoxymethane (AOM) followed by dextransulfate sodium (DSS) exposure-based model of the condition although bothgenotypes provided similar reduction in the levels of systemic andcolonic inflammation. See FIG. 15, for example. When a mutation in the0-catenin pathway (Apc^(Min)) was the main driver for intestinaltumorigenesis, partial PARP-1 inhibition by gene heterozygosity orolaparib protected against the tumor burden in Apc^(Min/+) mice whilecomplete inhibition by gene knockout aggravated the burden. See FIG. 5and FIG. 22, for example. These differential effects were not mirroredwith respective effects on systemic or intestinal inflammation,splenomegaly, or cachexia as all conditions lowered the aforementionedtraits. Using a MCA-38 colon carcinoma cell-allograft mouse model, theopposing effects of PARP-1 gene dosages on intestinal tumorigenesisoccurred despite that they both provide a tumor suppressivemicroenvironment through a regulation of the function of Myeloid-DerivedSuppressor Cells (MDSCs). These results exemplify the complexity of therole of PARPs in colon tumorigenesis, inflammation, and immunity thatcould be harnessed to effectively treat not only colon cancer but alsoother cancers that exist within a tumor microenvironment, such asbreast, liver and prostate.

The results of the inventors' studies exemplify the complexity and thepotentially paradoxical roles of PARPs in cancer by using coloncarcinogenesis as a model. Achieving maximum inhibition of PARP to treatcancers with DNA repair deficiency (e.g. breast or ovarian cancers withmutations in BRCA1 gene) is critical to induce synthetic lethality ofcancer cells. However, partial inhibition may be the best approach toblocking inflammation-driven or APC mutation-driven (e.g. FAP) coloncancer. The focus on achieving maximal inhibition of PARP may be thereason for the failure of two recent clinical trials using olaparib(Lynparza™) on patients with advanced colon cancer as a monotherapy orin combination with irinotecan (Camptosar™), a topoisomerase Iinhibitor. In some instances, the patient may be developing resistanceto the drug, in part due to the high doses administered (such as 600mg/day).

In cancer, the normal intercellular interactions in tissues aredisrupted, and the tumor microenvironment evolves to accommodate thegrowing tumor. The tumor microenvironment (TME) refers to the cellularenvironment in which a tumor exists, including components such assurrounding blood vessels, immune cells, fibroblasts, bonemarrow-derived inflammatory cells, lymphocytes, signaling molecules andthe extracellular matrix (ECM). Referring to FIG. 6 which utilizes aMA-38 cell-based allograft (immunocompetent) model of colon cancer, PARPinhibition provides a tumor-suppressive microenvironment. Specifically,this example demonstrates the effect of inhibiting PARP only in theimmune cells of the subject (and not in the cancer cells), However, ofclinical relevance, when PARP is inhibited in both immune cells and incancer cells (as is the case when a PARP inhibitor is administered to asubject), low doses of PARP inhibitors selectively affect the tumormicroenvironment (such as MDSCs) but not cancer cells. See FIG. 5, forexample.

Tumor microenvironment is complex and is heavily influenced by immunesystem. Emerging immune cells that influence and/or drive tumorigenesisare known as Myeloid-derived suppressor cells (MDSCs). MDSCs are aheterogeneous population of cells that are defined by their myeloidorigin, immature state and ability to potently suppress T cellresponses. MDSCs migrate from the basement membrane (BM) and recruit tothe site of tumor by tumor-associated macrophages (TAM). MDSCs arepotent immune suppressors (i.e., immunosuppressive), which as a resultcontributes to tumor progression. Specifically, MDSCs can infiltrate adeveloping tumor and promote vascularization, inhibit major pathways ofimmunosurveillance, inhibit natural killer (NK) cell-dependentcytotoxicity, inhibit T and B cell proliferation, inhibit antigenpresentation by dendritic cells (DC), and drive M1 macrophagepolarization.

MDSCs are increasingly being viewed as important players in promotingprogression or even resistance of most cancers. Referring to theExamples, PARP-1 plays a role in the function of MDSCs. Again, partialinhibition of PARP-1 is sufficient to interfere with the suppressivecapacity of these cells (see FIG. 7 and FIG. 17, for example). The roleof PARP-1 in the function of MDSCs may be harnessed as an added therapyto block many forms of cancers including colon cancer.

Importantly, PARP-1 inhibition interferes with the suppressive capacityof MDSCs, while having little to no effect on T cell or dendritic cellfunction (see FIG. 18, for example).

Therapeutic Methods

Described herein are methods of treating a subject afflicted with atumor and/or cancer comprising administering to a subject a low dose ofa PARP inhibitor compound. The term “low dose” refers to a very smallquantity of the PARP inhibitor compound relative to thewell-established/conventional larger quantities (such as 600 mg/day)that are known to produce an effect in certain cancers with DNA repairdeficiency (e.g. breast or ovarian cancers with mutations in BRCA1gene). As described herein, a low dose of a PARP inhibitor compoundproduces a different effect than the well-established higher dose.Referring to FIG. 20, for example, low dose of a PARP inhibitor compoundis much more effective than the high dose in blocking colon cancer whenadministered to a subject after the clear development of tumors.

A low dose of a PARP inhibitor compound is a quantity that is effectivefor partial inhibition of PARP-1 enzymatic activity. In anotherembodiment, a low dose of a PARP inhibitor compound is a dose that isbelow that which represents the threshold for maximal and/or completeinhibition of enzymatic activity. “Partial inhibition” can refer to anymeasurable reduction in the enzymatic activity of a PARP that is lessthan maximal (i.e., complete) inhibition. For example, partialinhibition of a PARP can refer to reducing the enzymes activity to about50%, enzymatic activity, about 40% enzymatic activity, about 30%enzymatic activity, about 10% enzymatic activity, or about 1% enzymaticactivity. Referring to FIG. 5, for example, partial inhibition of PARP-1enzymatic activity (such as by about 50%) protects against, whilecomplete inhibition of PARP-1 activity aggravates, tumor burden.Referring to FIG. 15, for example, partial inhibition of PARP-1 activity(such as by about 50%) is more effective at reducing inflammation-drivencolon tumorigenesis than complete inhibition of PARP-1 activity.Mechanistically, partial inhibition of PARP-1 activity is sufficient toblock expression of inflammatory genes in primary colon epithelial cells(see FIG. 14, for example), indicating that it is not necessary toinhibit all enzymatic activity (as is the goal of large doses of PARPinhibitors) to reduce inflammation.

A low dose of a PARP inhibitor compound can refer to a dose that isabout 10× to 150× lower than what is currently prescribed (e.g. seedescription herein). For example, the low dose of a PARP inhibitorcompound comprises a dose that is about 10×, 20×, 30×, 40×, 50×, 60×,70×, 80×, 90×, 100×, 110×, 120×, 130×, 140×, or 150× lower than what iscurrently prescribed.

For example, certain studies currently administer to a subject 5 mg/kgper day of a PARP inhibitor compound to achieve an effect, wherein anembodiment of the invention can comprise a low dose less than 1 mg/kgper day, such as a dose of about 0.2 mg/kg per day of a PARP inhibitorcompound. Thus, a 60kg individual may be administered approximately 300mg per day of a PARP inhibitor to achieve an effect, whereas embodimentsof the invention may comprise administering to a subject about 12 mg perday of a PARP inhibitor compound. In other embodiments of the invention,a subject can be administered a PARP inhibitor at a dose of betweenabout 1 mg per day to about 30 mg per day. For example, embodiments ofthe invention comprise a dose of less than about 1 mg per day, about 1mg per day, about 5 mg per day, about 10 mg per day, about 15 mg perday, about 20 mg per day, about 25 mg per day, about 30 mg per day,about 35 mg per day, about 40 mg per day or about 50 mg per day. Otherembodiments comprise a dose of less than about 100 mg of olaparib. Forexample, less than about 75 mg of olaparib. For example, about 50 mg ofolaparib.

The terms “treat,” “treating” or “treatment” can refer to the lesseningof severity of a tumor or cancer, delay in onset of a tumor or cancer,slowing the growth of a tumor or cancer, slowing metastasis of cells ofa tumor or cancer, shortening of duration of a tumor or cancer,arresting the development of a tumor or cancer, causing regression of atumor or cancer, relieving a condition caused by a tumor or cancer, orstopping symptoms which result from a tumor or cancer. The terms“treat,” “treating” or “treatment”, can include, but are not limited to,prophylactic and/or therapeutic treatments. Referring to FIG. 5, forexample, partial inhibition of PARP-1 activity protects against tumorburden in vivo (e.g., reduces tumor number/mouse and tumor size), whilecomplete inhibition of PARP-1 activity aggravates tumor burden in vivo.

As used herein, the terms “tumor” and “cancer” can be usedinterchangeably, and generally refer to a physiological conditioncharacterized by the abnormal and/or unregulated growth, proliferationor multiplication of cells.

In embodiments, a “tumor” or “solid tumor” can refer to a solid mass oftissue that is of sufficient size such that an immune response can bedetected in the tissue. A tumor may be benign, premalignant, ormalignant. A tumor may be a primary tumor, or a metastatic lesion.Examples of cancers that are associated with tumor formation includebrain cancer, head & neck cancer, esophageal cancer, tracheal cancer,lung cancer, liver cancer stomach cancer, colon cancer, pancreaticcancer, breast cancer, ovarian cancer, cervical cancer, uterine cancer,bladder cancer, prostate cancer, testicular cancer, skin cancer, rectalcancer, melanoma, kidney cancer, and lymphomas. One of ordinary skill inthe art would be familiar with the many disease entities that can beassociated with tumor formation.

A “liquid tumor” can refer to neoplasia that is diffuse in nature asthey do not typically form a solid mass. Examples include neoplasia ofthe reticuloendothelial or haematopoetic system, such as lymphomas,myelomas and leukemias. Non-limiting examples of leukemias include acuteand chronic lymphoblastic, myeolblastic and multiple myeloma. Typically,such diseases arise from poorly differentiated acute leukemias, e.g.,erythroblastic leukemia and acute megakaryoblastic leukemia. Specificmyeloid disorders include, but are not limited to, acute promyeloidleukemia (APML), acute myelogenous leukemia (AML) and chronicmyelogenous leukemia (CML). Lymphoid malignancies include, but are notlimited to, acute lymphoblastic leukemia (ALL), which includes B-lineageALL and T-lineage ALL, chronic lymphocytic leukemia (CLL),prolymphocytic leukemia (PLL), hairy cell leukemia (HLL) andWaldenstrom's macroglobulinemia (WM). Specific malignant lymphomasinclude, non-Hodgkin lymphoma and variants, peripheral T cell lymphomas,adult T cell leukemia/lymphoma (ATL), cutaneous T-cell lymphoma (CTCL),large granular lymphocytic leukemia (LGF), Hodgkin's disease andReed-Sternberg disease.

The term “resistant cancer” or “resistant tumor” can be usedinterchangably with the phrase “cancer resistant to therapy”, and canrefer to both (i) a cancer that is resistant to at least one anti-canceragent, wherein the resistance is acquired after treatment with said atleast one anti-cancer agent, i.e. a resistance-acquired cancer and (ii)a cancer that is resistant to at least one anti-cancer agent wherein theresistance is de novo, i.e. a de novo resistant cancer wherein theresistance is present prior to treatment with said at least oneanti-cancer agent. The term “resistant cancer” can refer to cancer cellsthat are able to survive in the presence of at least one anti-canceragent whereas a normal, non-resistant cancer cell would either showsigns of cell toxicity, cell death or cellular senescence. The skilledperson can easily assess whether a cancer is a resistant cancer, namelyby assessing cell viability or apoptosis-inducing activity afterbringing a suitable anti-cancer agent in contact with a canceroriginating from a subject. The skilled person is aware of the existenceof standard assays to screen for resistant cancers, such as MTT assays,ATP-measurements and/or apoptosis-assays such as TUNEL, Cytochrome Crelease or Cleaved Caspase-3 assays. Referring to FIG. 50 and FIG. 51,for example, ultra-low doses of a PARP-inhibitor, olaparib, reversessteroid resistance in KOPT-K1 cells, a steroid-resistant leumekia cellline. Further, referring to FIG. 56, for example, the PARP-inhibitor,olaparib, can sensitize steroid-resistant cancer cells to anti-cancertreatment, including treatment with dexamethasone.

In embodiments, the formation and/or growth of the tumor is exacerbatedby chronic inflammation, the amount of which is dependent upon tumortype. Over time, chronic inflammation can cause DNA damage and lead tocancer. For example, people with chronic inflammatory bowel diseases,such as ulcerative colitis and Crohn disease, have an increased risk ofcolon cancer.

The approach as described herein (i.e., administration of a low dose ofa PARP inhibitor and/or a therapeutically effective amount of a PARPinhibitor, optionally in combination with at least one additionalanti-cancer immunotherapy, will provide clinical benefit, definedbroadly as any of the following: inhibiting an increase in cell volume,slowing or inhibiting worsening or progression of cancer cellproliferation, inducing tumor regression, reducing primary tumor size,reducing occurrence or size of metastasis, reducing or stopping tumorgrowth, inhibiting tumor cell division, killing a tumor cell, inducingapoptosis in a tumor cell, reducing or eliminating tumor recurrence.Referring to FIG. 5 and FIG. 21, for example, partial inhibition ofPARP-1 activity protects against (e.g., reduces tumor number/mouse andtumor size) tumor burden in vivo, while complete inhibition of PARP-1activity aggravates tumor burden in vivo. Notably, all large tumors areabsent in the subjects with partial inhibition of PARP-1.

In embodiments, the low dose of a PARP inhibitor will synergize with theat least one additional anti-cancer immunotherapy to provide clinicalbenefit. “Synergy” or “synergize” refers to an effect of a combinationthat is greater than additive of the effects of each component alone.For example, referring to FIG. 37, a metronomic dose of olaparibsynergizes with anti-PD1 therapy to eradicate MC-38 cell-based tumors inmice. As another example, referring to FIG. 46, a metronomic dose ofolaparib synergizes with anti-CTLA4 therapy to eradicate MC-38cell-based tumors in mice. For example, referring to FIG. 56, ultra-lowdoses of a PARP-inhibitor, olaparib, in combination with one or moreanti-cancer agents, such as a steroid and/or a γ-secretase inhibitor,synergize to kill steroid-resistant cell line T-ALL1.

“Tumor regression” can refer to a decrease in the overall size,diameter, cross section, mass or viability of a tumor; tumor markerreduction or a positive indication from other conventional indicia ofcancer diagnosis and prognosis that indicates a reduction or growthslowing of cancer cells, as a result of the treatment of a cancerpatient with compositions according to the present invention. Forexample, the administration of such compounds results in at least abouta 30 percent to 50 percent tumor regression, at least about a 60 to 75percent tumor regression, at least about an 80 to 90 percent tumorregression and at least about a 95 or a 99 percent tumor regression atone or more tumor sites in a cancer patient. Ideally, suchadministration results in the killing or eradication of viable tumorcells or completely eradicates the tumor cells at one or more tumorsites in a cancer patient, leading to a clinically observable remissionor other enhancement in health of a patient.

The term “inhibition of tumor progression” can refer to the ability of asubstance or compound to reduce or block the proliferation of, or todecrease growth and development of tumor cells. Further, inhibition oftumor progression can also refer to the ability of a compound orcomposition to decrease the likelihood that a cancer will progress to amore aggressive cancer, and/or will metastasize.

The term “cellular proliferation” can refer to a phenomenon by which thecell number, such as a tumor cell number, has changed as a result ofcell division. This term can also encompass cell growth by which thecell morphology has changed (e.g., increased in size) consistent with aproliferative signal.

Also described herein are compositions and methods for modulating thetumor microenvironment. The term “modulate” can refer to the ability ofa compound to change the tumor microenvironment in some measurable wayas compared to an appropriate control. For example the PARP inhibitorcompound reduces the activity of myeloid derived suppressor cells(MDSCs). In embodiments, the PARP inhibitor compound reduces the tumorsuppressive activity of MDSCs. Modulation of the tumor microenvironmentcan be measured by, for example, assessment of immune cells within abiopsy (such as by FACS using markers specific to MDSC, CD8, NK, DC).

Aspects of the invention are also drawn towards compositions and methodsfor enhancing T cell function. Referring to FIG. 47, for example, low ofolaparib enhances while a high concentration decreases T cell functionin vitro.

Aspects of the invention can also be drawn towards compositions andmethods of sensitizing resistant tumors to cytotoxic T cells. Withoutwishing to be bound by theory, resistance to T cells is multifactorialbut the compositions and methods described herein can reverse theresistance (i.e., sensitize the cancer cells) to cytotoxic T cells. Forexample, embodiments can enhance the killing function of cytotoxic Tcells and thus reverse the resistance.

Administration

Described herein are methods of treating a subject afflicted with atumor and/or cancer comprising administering to a subject a low dose ofa PARP inhibitor compound. The term “administration” can refer tointroducing a PARP inhibitor compound or composition comprising the sameinto a subject. In general, any route of administration can be utilized.Non-limiting examples of routes of administration comprise parenteral(e.g., intravenous), intraperitoneal, oral, topical, subcutaneous,peritoneal, intraarterial, inhalation, vaginal, rectal, nasal,introduction into the cerebrospinal fluid, or instillation into bodycompartments. In some embodiments, administration is intraperitoneal.Additionally, or alternatively, in some embodiments, administration isparenteral. In some embodiments, administration is intravenous. In otherembodiments, administration is orally.

In embodiments, the PARP inhibitor compound can be administered to asubject before, during or after the development of a tumor or cancer.See, for example, FIGS. 19 and 20. In some embodiments, the PARPinhibitor compound is used as a prophylactic and is administeredcontinuously to subjects with a propensity to develop a tumor. In someembodiments, the PARP inhibitor compound is administered to a subjectduring or as soon as possible after the development of a tumor. In someembodiments, the administration of the PARP inhibitor compound isinitiated within the first 48 hours of the onset of the symptoms, withinthe first 6 hours of the onset of the symptoms, or within 3 hours of theonset of the symptoms. In some embodiments, the initial administrationof the PARP inhibitor compound is via any route practical, such as, forexample, an intravenous injection, a bolus injection, infusion over 5minutes to about 5 hours, a pill, a capsule, transdermal patch, buccaldelivery, intraperitoneally and the like, or combination thereof. ThePARP inhibitor compound should be administered as soon as is practicableafter the onset of a cancer is detected or suspected, and for a lengthof time necessary for the treatment of the cancer, such as, for example,from about 1 month to about 3 months. The length of treatment can varyfor each subject, and the length can be determined using the knowncriteria. In some embodiments, the PARP inhibitor compound isadministered for at least 2 weeks, between about 1 month to about 5years, or from about 1 month to about 3 years.

The terms “co-administration” or the like, as used herein, can refer tothe administration of a PARP inhibitor compound and at least oneadditional compound, such as a second PARP inhibitor compound or ananti-cancer agent, such as anti-PD1, to a single subject, and isintended to include treatment regimens in which the compounds and/oragents are administered by the same or different route ofadministration, in the same or a different dosage form, and at the sameor different time. In other embodiments, the second anti-cancer agentcan be a checkpoint-blockade antibody, a γ-secretase inhibitor, or asteroid.

An “anti-neoplastic agent”, “anti-tumor agent”, or “anti-cancer agent”can refer generally to any agent used in the treatment of cancer. Suchagents can be used alone or in combination with other compounds and canalleviate, reduce, ameliorate, prevent, or place or maintain in a stateof remission of clinical symptoms or diagnostic markers associated withneoplasm, tumor or cancer.

In embodiments, the anti-cancer agent can be a gamma secretaseinhibitor. As used herein, “gamma secretase inhibitor” can refer to anymolecule that inhibits gamma secretase or signaling events caused by theactivity of gamma secretase. Gamma-secretase inhibitors are known to theskilled artisan, and non-limiting examples of gamma-secretase inhibitorsinclude PF-03084014 or BMS-906024.

According to the National Cancer Institute, PF-03084014 is also referredto as nirogacestat, and is s selective gamma secretase (GS) inhibitorwith antitumor activity. Nirogacestat binds to GS, blocking proteolyticactivation of Notch receptors; Notch signaling pathway inhibition mayfollow, which may result in the induction of apoptosis in tumor cellsthat overexpress Notch. The integral membrane protein GS is amulti-subunit protease complex that cleaves single-pass transmembraneproteins, such as Notch receptors, at residues within theirtransmembrane domains. Overexpression of the Notch signaling pathway hasbeen correlated with increased tumor cell growth and survival.

According to the National Cancer Institute, BMS-906024 can also bereferred to as GS/pan-Notch inhibitor AL101, and is a small-moleculegamma secretase (GS) and pan-Notch inhibitor, with antineoplasticactivity. Upon intravenous administration, GS/pan-Notch inhibitor AL101binds to GS and blocks activation of Notch receptors, which may inhibitthe proliferation of tumor cells with an overly-active Notch pathway.The integral membrane protein GS is a multi-subunit protease complexthat cleaves single-pass transmembrane proteins, such as Notchreceptors, at residues within their transmembrane domains that lead totheir activation. Overactivation of the Notch signaling pathway, oftentriggered by activating mutations, has been correlated with increasedcellular proliferation and poor prognosis in certain tumor types.

In embodiments, the anti-cancer agent can be a steroid, which is ahydrophobic lipid molecule with a characteristic four-ringed structure.Steroids can be used in the treatment of cancer. Thus, anti-cancersteroids are known to the skilled artisan, and include prednisolone,prednisone, methylprednisolone, dexamethasone, and hydrocortisone.

An “anti-inflammatory” agent can refer generally to any agent that isused to reduce inflammation.

In embodiments, the anti-cancer agent can be an anti-cancerimmunotherapy. The skilled artisan will recognize that any anti-cancerimmunotherapy may be useful in embodiments as described herein. Oneclass of anti-cancer immunotherapies that can be used in embodiments ofthe invention include checkpoint blockade immunotherapies, such asanti-PD1 antibodies, anti-CTLA4 antibodies, or anti-PDL1 antibodies.Such antibodies can also be referred to as checkpoint blockadeinhibitors. The term “immune checkpoint” refers to a molecule such as aprotein in the immune system which provides inhibitory signals to itscomponents in order to balance immune reactions. Known immune checkpointproteins comprise CTLA-4, PD-1 and its ligands PD-L1 and PD-L2 and inaddition LAG-3, BTLA, B7H3, B7H4, TIM3, MR. The pathways involving LAGS,BTLA, B7H3, B7H4, TIM3, and KIR are recognized in the art to constituteimmune checkpoint pathways similar to the CTLA-4 and PD-1 dependentpathways (see e.g. Pardoll, 2012. Nature Rev Cancer 12:252-264; Mellmanet al., 2011. Nature 480:480-489).

In other embodiments, the anti-cancer agent can be an inhibitor ofindoleamine 2,3-dioxygenase-1 (i.e., IDO inhibitor). The IDO1 enzyme isactivated in many human cancers in tumor, stromal and innate immunecells where its expression tends to be associated with poor prognosis.Its role in immunosuppression is multifaceted, involving the suppressionof CD8+ T effector cells and natural killer cells as well as increasedactivity of CD4+ T regulatory cells (Treg) and myeloid-derivedsuppressor cells (MDSC). In tumor neovascularization, IDO1 acts as a keynode at the regulatory interface between IFN-y and IL-6 that shifts theinflammatory milieu towards promoting new blood vessel development. See,for example, Prendergast, George C., et al. “Discovery of IDO1inhibitors: from bench to bedside.” Cancer research 77.24 (2017):6795-6811. Thus, embodiments herein can comprise a therapeuticcombination of a PARP inhibitor compound and an IDO inhibitor. Forexample, the IDO inhibitor can be a small molecule inhibitor, such asEpacadostat, Indoximod, and Navoximod.

A therapeutically effective amount of a compound, an antibody, or acombination thereof, can relate generally to the amount needed toachieve a therapeutic objective. Referring to the examples herein,therapeutically effective amounts of a PARP-1 inhibitor and animmunotherapy are shown to achieve an objective of reducing tumorgrowth. Therapeutically effective amounts can depend on the severity andcourse of the cancer, previous therapy, the subject's health status,weight, and response to the drugs, and the judgment of the treatingphysician. Prophylactically effective amounts depend on the subject'sstate of health, weight, the severity and course of the disease,previous therapy, response to the drugs, and the judgment of thetreating physician.

In some embodiments, the PARP inhibitor compound is administered to thesubject on a regular basis, e.g., three times a day, two times a day,once a day, every other day or every 3 days. In other embodiments, thePARP inhibitor compound is administered to the subject on anintermittent basis, e.g., twice a day followed by once a day followed bythree times a day; or the first two days of every week; or the first,second and third day of a week. In some embodiments, intermittent dosingis as effective as regular dosing. In further or alternativeembodiments, the PARP inhibitor compound is administered only when thepatient exhibits a particular symptom, e.g., the onset of pain, or theonset of a fever, or the onset of an inflammation, or the onset of askin disorder. If two or more compounds are administered, dosingschedules of each compound can depend on the other or can be independentof the other.

In an embodiment, the administration of the PARP inhibitor compound canbe administered chronically, that is, for an extended period of time,including throughout the duration of the subject's life in order toameliorate or otherwise control or limit the symptoms of the subject'sdisorder.

In another embodiment, the administration of the PARP inhibitor compoundcan be given continuously; alternatively, the dose of drug beingadministered can be temporarily reduced or temporarily suspended for acertain length of time (i.e., a “drug holiday”). The length of the drugholiday can vary between 2 days and 1 year, including by way of exampleonly, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, 10 days, 12 days,15 days, 20 days, 28 days, 35 days, 50 days, 70 days, 100 days, 120days, 150 days, 180 days, 200 days, 250 days, 280 days, 300 days, 320days, 350 days, or 365 days. The dose reduction during a drug holidaymay be from 10%-100%, including, by way of example only, 10%, 15%, 20%,25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%,95%, or 100%.

In embodiments, a maintenance regimen can be administered if necessary,such as once a subject's condition has improved. Subsequently, thedosage or the frequency of administration of the PARP inhibitor compoundcan be reduced, for example as a function of the symptoms or tumor size,to a level at which the individual's improved condition is retained.Individuals can, however, require intermittent treatment on a long-termbasis upon any recurrence of symptoms.

The amount of the PARP inhibitor compound administered to a subject canvary depending upon factors such as the particular compound, cancer andits severity, the identity (e.g., weight) of the subject or host in needof treatment, and is determined according to the particularcircumstances surrounding the case, including, e.g., the specific agentsbeing administered, the routes of administration, the tumor beingtreated, and the subject or host being treated.. In general, however,doses employed for adult human treatment will typically be in the rangeof about 0.02 mg per day to about 50 mg/day, or from about 1 mg per dayto about 30 mg per day. For example, embodiments of the inventioncomprise a dose of about 0.1 mg per day, about 1 mg per day, about 5 mgper day, about 10 mg per day, about 15 mg per day, about 20 mg per day,about 25 mg per day, about 30 mg per day, about 35 mg per day, about 40mg per day or about 50 mg per day. The desired dose of each compound canbe presented in a single dose or as divided doses administeredsimultaneously (or over a short period of time) or at appropriateintervals, for example as two, three, four or more sub-doses per day.

The PARP inhibitor compound can be provided in a unit dosage formsuitable for single administration of precise dosages. The unit dosagemay be in the form of a package containing discrete quantities of thecompound. Non-limiting examples are packaged tablets or capsules, andpowders in vials or ampoules. Aqueous suspension compositions can bepackaged in single-dose non-reclosable containers. Alternatively,multiple-dose reclosable containers can be used, in which case it istypical to include a preservative in the composition. By way of exampleonly, formulations for parenteral injection may be presented in unitdosage form, which include, but are not limited to ampoules, or inmulti-dose containers, with an added preservative.

It is understood that a medical professional will typically determinethe dosage regimen in accordance with a variety of factors. Thesefactors include the cancer and/or tumor from which the subject suffers,the degree of metastasis, as well as the age, weight, sex, diet, andmedical condition of the subject.

Aspects of the invention are further drawn to methods of administering aPARP inhibitor compound at a metronomic dose.

Metronomic Therapy

The invention also provides metronomic dosing regime. There is provideda method of administering to a subject a composition comprising a doseof a PARP inhibitor compound (such as olaparib) based on a metronomicdosing regime. The methods are applicable to methods of treatment thatcan provide clinical benefit, defined broadly as any of the following:inhibiting an increase in tumor volume, slowing or inhibiting worseningor progression of cancer cell proliferation, inducing tumor regression,reducing primary tumor size, reducing occurrence or size of metastasis,reducing or stopping tumor growth, inhibiting tumor cell division,killing a tumor cell, inducing apoptosis in a tumor cell, reducing oreliminating tumor recurrence.

“Metronomic dosing regime” can refer to frequent administration of aPARP inhibitor compound without prolonged breaks (or drug holidays) at adose below the established maximum tolerated dose (MTD) via atraditional schedule with breaks (hereinafter also referred to as a“standard MTD schedule” or a “standard MTD regime”). In metronomicdosing, the same, lower, or higher cumulative dose over a certain timeperiod as would be administered via a standard MTD schedule mayultimately be administered. In some cases, this is achieved by extendingthe time frame and/or frequency during which the dosing regime isconducted while decreasing the amount administered at each dose.Generally, the PARP inhibitor compound administered via the metronomicdosing regime of the present invention is better tolerated by theindividual. Metronomic dosing can also be referred to as maintenancedosing or chronic dosing.

In some variations, there is provided a method of administering acomposition comprising a PARP inhibitor compound, wherein the PARPinhibitor compound is administered over a period of time, such as atleast one month, wherein the interval between each administration is nomore than about 1 day, about 2 days, about 3 days, about 4 days, about 5days, about 6 days, about 7 days, about 14 days, about 28 days, andwherein the dose of the PARP inhibitor compound at each administrationis about 0.25% to about 50% of its maximum tolerated dose following atraditional dosing regime. In embodiments, the dose of the PARPinhibitor compound at each administration is about 0.25% to about 35% ofits maximum tolerated dose following a traditional dosage regimen. Insome variations, the dosing of the PARP inhibitor compound (such asolaparib) per administration is less than about any of 1%, 2%, 3%, 4%,5%, 6%, 7%, 8%, 9%, 10%, 11%, 12%, 13%, 14%, 15%, 18%, 20%, 22%, 24%,25%, 27%, 30%, 32%, 35%, 40%, 45%, or 50% of the MTD for the same PARPinhibitor compound in the same formulation following a given traditionaldosing schedule. Traditional dosing schedule refers to the dosingschedule that is generally established in a clinical setting, anddepends on the PARP inhibitor administered to the subject. For example,a traditional dosing schedule for PARP inhibitor compound can be 100mg-300 mg compound (depending on the PARP inhibitor) twice a day. Asanother example, the maximum tolerated dose of Talazoparib isadministered as 1 mg/day.

In some variations, the dosing of the PARP inhibitor compound peradministration is between about 0.25% to about 25% of the correspondingMTD value, including for example any of about 0.25% to about 20%, about0.25% to about 15%, about 0.25% to about 10%, of the corresponding MTDvalue. The MTD value for a PARP inhibitor compound following atraditional dosing schedule is known or can be easily determined by aperson skilled in the art.

In some variations, there is provided a method of administering acomposition comprising a PARP inhibitor compound, wherein the PARPinhibitor compound is administered over a period of at least one month,wherein the interval between each administration is no more than about aweek. For example, the interval between each administration may be nomore than about 1 day, no more than about 2 days, no more than about 3days, no more than about 4 days, no more than about 5 days, no more thanabout 6 days, or no more than about 7 days.

Dosing frequency for the PARP inhibitor compound includes, but is notlimited to, at least about any of once a week, twice a week, three timesa week, four times a week, five times a week, six times a week, ordaily. Typically, the interval between each administration is less thanabout a week, such as less than about any of 6, 5, 4, 3, 2, or 1 day. Insome variations, the interval between each administration is constant.For example, the administration can be carried out daily, every twodays, every three days, every four days, every five days, or weekly. Insome variations, the administration can be carried out twice daily,three times daily, or more frequent.

The metronomic dosing regimes described herein can be extended over anextended period of time, such as from about a month, up to about threeyears, or longer than 3 years. For example, the dosing regime can beextended over a period of any of about 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12, 18, 24, 30, and 36 months. Generally, there are no breaks in thedosing schedule.

The cumulative dose of the PARP inhibitor compound administered by themetronomic regime may be higher than that administered according to astandard MTD dosing schedule over the same time period. In somevariations, the cumulative dose of the PARP inhibitor compoundadministered by the metronomic regime equals to or is lower than that ofthe PARP inhibitor compound administered according to a standard MTDdosing schedule over the same time period.

It is understood that the teaching provided herein is for examples only,and that metronomic dosing regime can be routinely designed inaccordance with the teachings provided herein and based upon theindividual standard MTD schedule, and that the metronomic dosing regimeused in these experiments merely serves as one example of possiblechanges in dosing interval and duration which are made to a standard MTDschedule to arrive at an optimal metronomic dosing regime.

The metronomic dosing regime described herein may be used alone as atreatment of a proliferative disease, or carried out in a combinationtherapy context, such as the combination therapies described herein. Forexample, the metronomic dosing regime described herein may be carriedout in a combination therapy with at least one additional anti-cancertherapy, such as an anti-PD1 immunotherapy (e.g., checkpoint blockadetargets) or an IDO inhibitor.

In some variations, the metronomic therapy dosing regime may be used incombination or conjunction with other established therapies administeredvia standard MTD regimes. By “combination or in conjunction with” it ismeant that the metronomic dosing regime of the present invention isconducted either at the same time as the standard MTD regime ofestablished therapies, or between courses of induction therapy tosustain the benefit accrued to the individual by the induction therapy,the intent is to continue to inhibit tumor growth while not undulycompromising the individual's health or the individual's ability towithstand the next course of induction therapy. For example, ametronomic dosing regime may be adopted after an initial short course ofMTD chemotherapy.

In some variations, the PARP inhibitor compound is administered at leastabout any of 1×, 2×, 3×, 4×, 5×, 6×, 7× (i.e., daily) a week. In somevariations, the intervals between each administration are less thanabout any of 7 days, 6 days, 5 days, 4 days, 3 days, 2 days, and 1 day.In some variations, the PARP inhibitor compound is administered over aperiod of at least about any of 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 18,24, 30 and 36 months.

Compounds, Pharmaceutical Formulations, and Compositions

Described herein are methods of treating a subject afflicted with atumor and/or cancer comprising administering to a subject a low dose ofa PARP inhibitor compound.

As described herein, the term “PARP” is used herein to refer to a familyof proteins of the enzyme poly(ADP- ribose) polymerase. For example, thePARP can be poly (ADP-ribose) polymerase-1 (PARP-1) or poly (ADP-ribose) polymerase-2 (PARP-2).

The phrase “inhibition of PARP” can refer to inhibiting or reducing theactivity of one or more enzymes of the poly (ADP- ribose) polymerase(PARP) family. For example, a PARP-1 inhibitor will inhibit or reducethe activity of the PARP-1 protein. In embodiments, the activity of thePARP-1 protein is reduced by about 5%, about 10%, about 20%, about 30%,about 40%, about 50%, about 60%, about 70%, about 80%, about 90% orabout 100%. In embodiments, the amount of PARP mRNA and/or PARP proteinis reduced by the PARP inhibitor (such as by siRNA, for example). Inother embodiments, the amount of PARP mRNA and/or PARP protein is notreduced, but the activity of the enzyme itself is reduced or inhibited.

Definition of standard chemistry terms are found in reference works,including Carey and Sundberg “ADVANCED ORGANIC CHEMISTRY 4^(TH) ED.”Vols. A (2000) and B (2001), Plenum Press, New York, the entire contentsof which are incorporated herein by reference. Unless otherwiseindicated, conventional methods of mass spectroscopy, NMR, HPLC, proteinchemistry, biochemistry, recombinant DNA techniques and pharmacology,within the skill of the art can be employed. Unless specific definitionsare provided, the nomenclature employed in connection with, and thelaboratory procedures and techniques of, analytical chemistry, syntheticorganic chemistry, and medicinal and pharmaceutical chemistry describedherein are those known in the art. Standard techniques are optionallyused for chemical syntheses, chemical analyses, pharmaceuticalpreparation, formulation, and delivery, and treatment of patients.

The PARP inhibitor compounds described herein can be selective forPARP-1, but can also be selective for PARP-2, PARP-3, or any combinationof PARP-1, PARP-2, and/or PARP-3 (such as rucaparib). In embodiments,the PARP inhibitor compound is a PARP-1 inhibitor compound. Inembodiments, the PARP inhibitor compound is a PARP-1/PARP-2 inhibitorcompound. In still other embodiments, the PARP inhibitor compound is aPARP-1/PARP-2/PARP-3 inhibitor compound.

In an embodiment, the PARP inhibitor compound is a compound of Formula(I).

In some embodiments, the PARP inhibitor is Olaparib (i.e., AZD,Lynparza). Non-limiting examples of other PARP inhibitors comprisenicotinamide analogues (such as 3-Aminobenzamide), TIQ-A, NU1025, PJ-34,AIQ, PD12873, ABT-888, AG014699, among others.

In an embodiment. the PARP inhibitor romnnund is a comonund of Formula(II):

In an embodiment, the PARP inhibitor is Rucaparib (i.e., Rubraca).

In an embodiment, the PARP inhibitor compound is a compound of Formula(III):

In an embodiment, the PARP inhibitor is Niraparib (i.e., Zejula).

In an embodiment, the PARP inhibitor compound is a compound of Formula(III):

In an embodiment, the PARP inhibitor is Velaparib.

Pharmaceutical compositions comprising a PARP inhibitor compound can beformulated in a conventional manner using one or more physiologicallyacceptable carriers including excipients and auxiliaries whichfacilitate processing of the active compounds into preparations whichcan be used pharmaceutically. Proper formulation is dependent upon theroute of administration chosen. A summary of pharmaceutical compositionsdescribed herein is found, for example, in Remington: The Science andPractice of Pharmacy, Nineteenth Ed (Easton, Pa.: Mack PublishingCompany, 1995); Hoover, John E., Remington's Pharmaceutical Sciences,Mack Publishing Co., Easton, Pa. 1975; Liberman, H. A. and Lachman, L.,Eds., Pharmaceutical Dosage Forms, Marcel Decker, New York, N.Y., 1980;and Pharmaceutical Dosage Forms and Drug Delivery Systems, Seventh Ed.(Lippincott Williams & Wilkins 1999), the entire contents of which areincorporated by reference herein in their entireties.

PARP inhibitor compounds can be incorporated into pharmaceuticalcompositions suitable for administration to a subject. A pharmaceuticalcomposition can refer to a mixture of a PARP inhibitor compound withother chemical components, such as carriers, stabilizers, diluents,dispersing agents, suspending agents, thickening agents, and/orexcipients. The use of such media and agents for pharmaceutically activesubstances is well known in the art. Any conventional media or agentthat is compatible with the active compound can be used. Supplementaryactive compounds can also be incorporated into the compositions.

For example, such compositions can comprise a compound of formula (I)and a pharmaceutically acceptable carrier. In embodiments, thecomposition comprises a PARP inhibitor and a pharmaceutically acceptablecarrier. For example, non-limiting examples of pharmaceuticallyacceptable carriers comprise solid or liquid fillers, diluents, andencapsulating substances, including but not limited to lactose,dextrose, sucrose, sorbitol, mannitol, xylitol, erythritol, maltitol,starches, gum acacia, alginate, gelatin, calcium phosphate, calciumsilicate, cellulose, methyl cellulose, microcrystalline cellulose,polyvinylpyrrolidone, water, methyl benzoate, propyl benzoate, talc,magnesium stearate, and mineral oil.

Pharmaceutical compositions can be manufactured in a conventionalmanner, such as, by way of example only, by means of conventionalmixing, dissolving, granulating, dragee-making, levigating, emulsifying,encapsulating, entrapping or compression processes.

The pharmaceutical compositions described herein can be administered byany suitable administration route, including but not limited to, oral,interparenteral, parenteral (e.g., intravenous, subcutaneous,intramuscular), intraperitoneal, intranasal, buccal, topical, rectal, ortransdermal administration routes.

The pharmaceutical compositions described herein are formulated into anysuitable dosage form, including but not limited to, aqueous oraldispersions, liquids, gels, syrups, elixirs, slurries, suspensions andthe like, for oral ingestion by an individual to be treated, solid oraldosage forms, aerosols, controlled release formulations, fast meltformulations, effervescent formulations, lyophilized formulations,tablets, powders, pills, dragees, capsules, delayed releaseformulations, extended release formulations, pulsatile releaseformulations, multiparticulate formulations, and mixed immediate releaseand controlled release formulations. In some embodiments, thecompositions are formulated into capsules. In some embodiments, thecompositions are formulated into solutions (for example, for IVadministration).

For example, pharmaceutical compositions suitable for injectable useinclude sterile aqueous solutions (where water soluble) or dispersionsand sterile powders for the extemporaneous preparation of sterileinjectable solutions or dispersions. For intravenous administration, forexample, suitable carriers include physiological saline, bacteriostaticwater, Cremophor EM™ (BASF, Parsippany, N.J.) or phosphate bufferedsaline (PBS). In all cases, the composition must be sterile and shouldbe fluid to the extent that easy syringability exists. It must be stableunder the conditions of manufacture and storage and must be preservedagainst the contaminating action of microorganisms such as bacteria andfungi. The carrier can be a solvent or dispersion medium containing, forexample, water, ethanol, a pharmaceutically acceptable polyol likeglycerol, propylene glycol, liquid polyetheylene glycol, and suitablemixtures thereof. The proper fluidity can be maintained, for example, bythe use of a coating such as lecithin, by the maintenance of therequired particle size in the case of dispersion and by the use ofsurfactants. Prevention of the action of microorganisms can be achievedby various antibacterial and antifungal agents, for example, parabens,chlorobutanol, phenol, ascorbic acid, and thimerosal. In many cases, itcan be useful to include isotonic agents, for example, sugars,polyalcohols such as mannitol, sorbitol, sodium chloride in thecomposition. Prolonged absorption of the injectable compositions can bebrought about by including in the composition an agent which delaysabsorption, for example, aluminum monostearate and gelatin.

Sterile solutions can be prepared by incorporating the compound in therequired amount in an appropriate solvent with one or a combination ofingredients, such as those described herein, as required, followed byfiltered sterilization. Generally, dispersions are prepared byincorporating the active compound into a sterile vehicle which containsa basic dispersion medium and the required other ingredients from thoseenumerated herein. In the case of sterile powders for the preparation ofsterile injectable solutions, examples of useful preparation methods arevacuum drying and freeze-drying which yields a powder of the activeingredient plus any additional ingredient from a previouslysterile-filtered solution thereof.

The pharmaceutical solid dosage forms described herein optionallyinclude one or more pharmaceutically acceptable additives such as acompatible carrier, binder, filling agent, suspending agent, flavoringagent, sweetening agent, disintegrating agent, dispersing agent,surfactant, lubricant, colorant, diluent, solubilizer, moistening agent,plasticizer, stabilizer, penetration enhancer, wetting agent,anti-foaming agent, antioxidant, preservative, or one or morecombination thereof.

In still other aspects, using standard coating procedures, such as thosedescribed in Remington's Pharmaceutical Sciences, 20th Edition (2000), afilm coating is provided around the compositions. In some embodiments,the compositions are formulated into particles (for example foradministration by capsule) and some or all of the particles are coated.In some embodiments, the compositions are formulated into particles (forexample for administration by capsule) and some or all of the particlesare microencapsulated. In some embodiments, the compositions areformulated into particles (for example for administration by capsule)and some or all of the particles are not microencapsulated and areuncoated.

Kits

Described herein are methods of treating tumors and/or cancerscomprising administering to a subject a low dose of a PARP inhibitorcompound.

For use in therapeutic methods described herein, kits and articles ofmanufacture are also described herein. In some embodiments, such kitsinclude a carrier, package, or container that is compartmentalized toreceive one or more containers such as vials, tubes, and the like, eachof the container(s) including one of the separate elements to be used ina method described herein. Suitable containers include, for example,bottles, vials, syringes, and test tubes. The containers can be formedfrom a variety of materials such as glass or plastic.

The articles of manufacture provided herein contain packaging materials.Examples of pharmaceutical packaging materials include, but are notlimited to, blister packs, bottles, tubes, inhalers, pumps, bags, vials,containers, syringes, bottles, and any packaging material suitable for aselected formulation and intended mode of administration and treatment.A wide array of formulations of the compounds and compositions providedherein are contemplated as are a variety of treatments for any disorderthat benefit by inhibition of PARP-1, or in which PARP-1 is a mediatoror contributor to the symptoms or cause.

For example, a container may include a compound of Formula (I) and oneor more additional compounds. The container(s) optionally have a sterileaccess port (for example the container is an intravenous solution bag ora vial having a stopper pierceable by a hypodermic injection needle).Such kits optionally comprising a compound with an identifyingdescription or label or instructions relating to its use in the methodsdescribed herein.

A kit will typically include one or more additional containers, eachwith one or more of various materials (such as reagents, optionally inconcentrated form, and/or devices) desirable from a commercial and userstandpoint for use of a compound described herein. Non-limiting examplesof such materials include, but not limited to, buffers, diluents,filters, needles, syringes; carrier, package, container, vial and/ortube labels listing contents and/or instructions for use, and packageinserts with instructions for use. A set of instructions will alsotypically be included.

In some embodiments, a label is on or associated with the container. Alabel can be on a container when letters, numbers or other charactersforming the label are attached, molded or etched into the containeritself; a label can be associated with a container when it is presentwithin a receptacle or carrier that also holds the container, e.g., as apackage insert. A label can be used to indicate that the contents are tobe used for a specific therapeutic application. The label can alsoindicate directions for use of the contents, such as in the methodsdescribed herein.

In certain embodiments, a pharmaceutical composition comprising a PARPinhibitor is presented in a pack or dispenser device which can containone or more unit dosage forms. The pack can for example contain metal orplastic foil, such as a blister pack. The pack or dispenser device canbe accompanied by instructions for administration. The pack or dispensercan also be accompanied with a notice associated with the container inform prescribed by a governmental agency regulating the manufacture,use, or sale of pharmaceuticals, which notice is reflective of approvalby the agency of the form of the drug for human or veterinaryadministration. Such notice, for example, can be the labeling approvedby the U.S. Food and Drug Administration for prescription drugs, or theapproved product insert. Compositions containing a compound providedherein formulated in a compatible pharmaceutical carrier can also beprepared, placed in an appropriate container, and labeled for treatmentof an indicated condition.

EXAMPLES

Examples are provided below to facilitate a more complete understandingof the invention. The following examples illustrate the exemplary modesof making and practicing the invention. However, the scope of theinvention is not limited to specific embodiments disclosed in theseExamples, which are for purposes of illustration only, since alternativemethods can be utilized to obtain similar results.

Example 1

Complex Roles for PARP-1 in Colon Cancer, Inflammation, and TumorImmunity: Harnessing these Roles to Modulate Cancer

One of the critical objectives of our laboratory is to test thehypothesis that DNA repair enzymes such as PARP-1 play important rolesin not only cancer-related processes but also in the pathogenesis ofmany inflammatory diseases. Without wishing to be bound by theory, thefunction of PARP-1 in cancers is intimately related to its role inproviding alternative and efficient pathways to cancer cells to surviveespecially for those associated with defects in DNA repair (e.g. triplenegative breast and ovarian cancers), however, its role in inflammationmay be very different. The role of PARP-1 in DNA repair requires fullactivity of the enzyme as partial inhibition of PARP-1 has not beenassociated with defects in DNA repair. The purpose of the presentstudies is to clarify the roles of PARP-1 in colon inflammation andcancer and determine whether they are related.

Referring to FIG. 1, for example, we show that partial PARP-1 inhibition(50%) was very effective at reducing or even blocking expression ofinflammatory genes in response to LPS or TNF-α treatment and thatcomplete inhibition of the enzyme was not necessary to achieve maximaleffects. This appears to be due, in part, to a reduction in NF-κB-signaltransduction. The remarkable anti-inflammatory effects of PARP-1inhibition (partial or total) suggested that such inhibition would beprotective against chronic inflammation-driven colon carcinogenesis.

Referring to FIG. 2, for example, surprisingly, partial PARP-1inhibition by gene heterozygosity was more efficient than completeinhibition by gene knockout at reducing chronic inflammation-drivencolon tumorigenesis using an azoxymethane (AOM) followed by dextransulfate sodium (DSS) exposure-based model of the condition although bothgenotypes provided similar reduction in the levels of systemic andcolonic inflammation.

Referring to FIG. 5, for example, when a mutation in the β-cateninpathway (Apc^(Min)) was the main driver for intestinal tumorigenesis,partial PARP-1 inhibition by gene heterozygosity or olaparib protectedagainst the tumor burden in Apc^(Min/+) mice while complete inhibitionby gene knockout aggravated the burden. These differential effects werenot mirrored with respective effects on systemic or intestinalinflammation, splenomegaly, or cachexia as all conditions lowered theaforementioned traits.

Referring to FIG. 20, for example, using an MCA-38 colon carcinomacell-allograft mouse model, we show that the opposing effects of PARP-1gene dosages on intestinal tumorigenesis occurred despite that they bothprovide a tumor suppressive microenvironment through a regulation of thefunction of Myeloid-Derived Suppressor Cells (MDSCs). These resultsexemplify the complexity of the role of PARP-1 in colon tumorigenesis,inflammation, and immunity that could be harnessed to effectively treatnot only colon cancer but also others.

Example 2

PARP-1 Heterozygosity Noticeably Protects Against Tumorigenesis inAPC^(min/+) mice.

Without wishing to be bound by theory, this protection can be due, inpart, to the anti-inflammatory effects of PARP-1 inhibition at the levelof the colon as well as systemically.

Although PARP-1 nullizigosity promotes an anti-inflammatory effect, itactually aggravates tumorigenesis in APC^(min/+) mice. Preliminarystudies using CGH analysis suggests that such effects may be associatedwith an increase in genomic instability, another driving force in coloncarcinogenesis.

Using a low and a high doses of the PARP inhibitor olaparib, we wereable to reproduce the protective effect of PARP-1 gene heterozygositybut not nullizigosity in APC^(min/+) mice . Of note, using a high doseof olaparib was unreasonably expected to inhibit PARP-1 in a mannersimilar to that achieved by PARP-1 knockout.

It is noteworthy, however, that the pro-tumorigenic effect of PARP-1nullizigosity may actually be associated with changes within thetransformed colon epithelial cells rather the overall host response.Indeed, PARP-1 nullizigosity promotes a tumor-suppressive rather than atumor-promoting host response as shown by our results using theMCA-38-allograft model

When inflammation is the major driver, PARP-1 inhibition,pharmacologically or by gene knockout, protects against colontumorigenesis. However, PARP-1 heterozygosity was more protectiveagainst AOM/DSS-induced tumor burden than gene knockout. Thisdiscrepancy may also be associated with the effect of PARP-1 knockout(not heterozygosity) in genomic instability.

Overall these studies call for a serious caution in the current approachto use PARP inhibitors including olaparib as a therapeutic strategyagainst colon cancer.

Referring to FIG. 1, for example, colon epithelial cells were treatedwith TNF-α for the indicated time intervals in the presence or absence 5μM of the PARP inhibitor AZD2281. Cells were collected and proteinextracts were subjected to immunoblot analysis with antibodies to VCAM-1and COX2. AZD2281inhibits the expression of inflammatory markers.

PARP-1 heterozygosity decreased tumorigenesis of the APCMin /+ mice, notPARP-1 nullizigosity. (A) Tumor numbers of small and large intestinewere counted at 16-week-old of age in APCMin/+mice (n=13)ApcMin/+PARP+/−mice (n=14) and APCMin/+PARP−/− (n=12). (B) Tumors wereseparated based on their size.

Example 3

Low Doses of PARP Inhibitors as a Novel Strategy to Enhance Anti-TumorImmunity

The objective is to establish a better understanding of the differentaspects of the contribution of poly(ADP-ribose) polymerase-1 (PARP-1) intumorigenesis in such a way that it can be targeted in cancers otherthan those with BRCA mutations. Cancers including that of the colon arerank among the most common diseases in the US as well as worldwide withtotal national expenditure for care of affected individuals exceeding$125 billion. These studies will provide important insights on theutility of PARP inhibitors in targeting cancer cells indirectly bypromoting an advantage to the host to use its immune system to attackcancer cells using the drugs at low doses, which reduces the potentialfor resistance and manifestation of side effects.

SUMMARY

Targeting poly(ADP-ribose) polymerase (PARP) is a new strategy in cancertherapy. For example, this therapy is primarily effective inBRCA-defective cancers (approved for advanced ovarian cancer). Theultimate goal of this current therapy is maximal inhibition of PARP toachieve “synthetic lethality” taking advantage of the inability ofBRCA-deficient cancer cells to repair DNA. See FIG. 13, for example.This strategy is limited by the requirement for a constantadministration of high doses of the drugs (e.g. olaparib/Lynparza™) andthe alarming rise of resistance to the drugs. Past studies on theutility of PARP-1 as a therapeutic target were based on the use ofPARP-1^(−/−) mice, very high doses of PARP inhibitors (such as 300mg/day or more of PARP inhibitors), and immuno-compromised mice.Clinical trials exploring the efficacy of PARP inhibitors on severalcancers lead to disappointing results. Because of such focus, manyimportant aspects of PARP inhibition could not be harnessed for fullclinical benefits.

Results herein show that partial PARP-1 inhibition (by geneheterozygosity or a low dose of olaparib) provides excellent protectionagainst intestinal tumor burden in APC^(Min/+) mice while extensiveinhibition of the enzyme (by gene knockout or a high dose of olaparib)was ineffective or aggravated such burden. These divergent effectsoccurred despite a blockade in intra-tumoral and systemic inflammationand a promotion of tumor suppressive microenvironment.

Myeloid-Derived Suppressor Cells (MDSCs) recruitment and expansion aremajor determinants of cancer progression and resistance to therapies bymodulating the tumor-killing capacity of the immune system. Results showthat PARP-1 plays a key role in MDSC function and that partialinhibition of the enzyme is sufficient to block the suppressive functionof these suppressor cells in a MCA-38 cell-based allograft model.Interestingly, anti-tumor immune cells (e.g. T, NK, and dendritic cells)are not affected even with maximal inhibition of PARP-1.

Without wishing to be bound by theory, high doses of PARP inhibitorssuppress MDSC function but with a concomitant enhancement of thetumorigenic effects of cancer cells by increasing genomic instability.However, low doses of PARP inhibitors selectively reduce the suppressiveactivity of MDSCs, decrease inflammation, and provide an advantage totumor-killing immune cell at reducing/blocking tumor progression withoutenhancing the tumorigenic traits of cancer cells.

This paradigm-shift will be tested by examining the relationship betweenPARP-1, its inhibition by decreasing doses of olaparib, and MDSCsdifferentiation, function, and recruitment to tumors using the allograftmodel and an ex vivo system. We will then examine whethermyeloid-specific or colon epithelial-specific deletion of PARP-1influences tumorigenesis and MDSC trafficking in a mouse model ofApc^(Min)-driven colon cancer. The results of the studies will allow usto establish a foundation on which we can demonstrate that PARP-1inhibition with low doses of drugs constitutes an extraordinaryopportunity to modulate the progression of colon cancer as well as manyothers by blocking MDSC recruitment and function, which potentiallyenhances the efficacy of many existing and future immunotherapeuticstrategies.

Description of Work

One of the hallmarks of tumor progression and resistance to therapy isthe recruitment of myeloid-derived cells that suppress cancercell-killing immune cells. Myeloid-Derived Suppressor Cells (MDSCs)recruitment and expansion represent critical events during cancerprogression. These cells can influence as well as they can be influencedby the tumor microenvironment. Selective interference with therecruitment and/or function of these cells represents an ideal approachto prevent tumor progression, enhance potency of existing therapies, andpromote tumor regression.

Targeting poly(ADP-ribose) polymerase (PARP) is a new strategy in cancertherapy. However, this therapy is primarily effective in BRCA-defectivecancers (approved for advanced ovarian cancer). The ultimate goal ofthis therapy is maximal inhibition of PARP to achieve “syntheticlethality” taking advantage of the inability of BRCA-deficient cancercells to repair DNA. This strategy is limited by the requirement for aconstant administration of high doses of the drugs (e.g.olaparib/LynparzaTM) and the premature emergence of resistance to thedrugs. Past studies on the utility of PARP-1 as a therapeutic targetwere based on the use of PARP-1^(−/−) mice, unreasonably high doses ofPARP inhibitors, and immuno-compromised mice. Clinical trials exploringthe efficacy of PARP inhibitors on several cancers lead to disappointingresults. Because of such focus, many important aspects of PARPinhibition could not be harnessed for full clinical benefits.

Results herein show that partial PARP-1 inhibition (by geneheterozygosity or a low dose of olaparib) provides excellent protectionagainst intestinal tumor burden in APC^(Min/+) mice while extensiveinhibition of the enzyme (by gene knockout (KO) or a high dose ofolaparib) was ineffective or aggravated such burden. These divergenteffects occurred despite a blockade in intra-tumoral and systemicinflammation and a promotion of a tumor suppressive microenvironment.Results show that PARP-1 plays a key role in MDSC function and thatpartial inhibition of the enzyme is sufficient to block the suppressivecapacity of these cells in a MCA-38 cell-based allograft model.Interestingly, anti-tumor immune cells such as T, NK, and dendriticcells are not affected by PARP-1 inhibition. More importantly, low dosesof olaparib are more effective than high doses in blocking MCA-38-basedtumors in WT mice.

Without wishing to be bound by theory, high doses of PARP inhibitors maysuppress MDSC function but with a concomitant enhancement of thetumorigenic effects of cancer cells by increasing genomic instability.However, low doses of PARP inhibitors selectively reduce the suppressiveactivity of MDSCs, decrease inflammation, and provide an advantage totumor-killing immune cell at reducing/blocking tumor progression withoutenhancing the tumorigenic traits of cancer cells.

To demonstrate this, we will perform studies using an integratedapproach including a MCA-38 colon adenocarcinoma cell-based allograftmodel and the APC^(Min)-based spontaneous intestinal tumorigenesismodel. We will take advantage of our newly generated C57BL/6 PARP-1conditional PARP-1^(fl/fl) mice under the control of hematopoietic cell-or colon epithelial-specific Cre strain. We will also use an ex vivocell culture model to address some aspects of this invention.Additionally, we will use PARP-1 depletion approaches primarilyshRNA-based partial knockdown to mimic PARP-1 gene heterozygosity andCRISPR/Cas9 to mimic PARP-1 knockout on MCA-38 cells.

We will test this paradigm-shift as follows:

1: Examine the relationship between PARP-1, its inhibition by decreasingdoses of olaparib, and MDSCs differentiation, intra-tumoral recruitmentand function using a MCA-38 colon adenocarcinoma cell-based allograftmodel and an ex vivo system.

2: Examine whether myeloid-specific or colon epithelial-specificdeletion of PARP-1 influences tumorigenesis and MDSC trafficking in amouse model of ApcMin-driven colon cancer.

The studies will demonstrate that PARP-1 inhibition with low doses ofdrugs constitutes an extraordinary opportunity to modulate theprogression of colon cancer as well as many others by enhancing theefficacy of many existing and future immunotherapeutic strategies.

Research Strategy

(a) Significance

A disappointing aspect about the old and new generation cancer therapiesis the emergence of drug resistance and the ability of the cancer cellto evade the immune system. PARP inhibitors are emerging as a promisingtherapy for several human cancers especially those driven bydeficiencies in non-PARP-associated DNA repair¹. Indeed, olaparib(Lynparza™) is now approved as a monotherapy for patients with advancedBRCA1-mutated ovarian cancer. Interestingly, several preclinical andclinical studies offered some hope for PARP inhibitors in the treatmentof other cancers with no obvious mutations in BRCA². Unfortunately, manyof the clinical trials failed. Recently, olaparib was tested in a phaseI³ and a phase II⁴ clinical trials on patients with advanced coloncancer as a monotherapy or in combination with irinotecan (Camptosar™),with disappointing results but encouraging more detailed studies.Without wishing to be bound by theory, the reason for the failure ofPARP inhibitors in treating non-BRCA1-mutated cancers is the fact thatwe still do not understand the intricacies of the role of the enzyme inthe pathogenesis of cancers including that of the colon.

One of our critical objectives is to unravel the unobvious functions ofDNA repair enzymes such as PARP-1 and test the hypothesis that theseenzymes play important roles not only in cancer cell-related processes(DNA repair, cell death, genomic integrity, etc.) but also ininflammatory and immune responses. The function of PARP-1 in cancers maybe intimately related to its ability to provide an alternative pathwayfor cancer cells to survive especially for those associated with defectsin DNA repairs⁵; however, the mechanism by which it contributes toinflammation may be very different. The role of PARP-1 in DNA repairrequires the full activity of the enzyme as partial inhibition of PARP-1has not been associated with major defects in DNA repair¹. Indeed,PARP-1 heterozygous cells or mice behave similarly to DNA damagingagents as the WT counterparts⁶. Interestingly, we reported that PARP-1heterozygosity (which reduces PARP-1 by ˜50%) or low doses of a PARPinhibitor substantially blocks atherosclerosis in high fat diet-fedApoE^(−/−) mice⁷. We have also shown that low doses of PARP inhibitors,including olaparib, protect against asthma⁷⁻¹¹.

MDSCs play a critical role in providing an advantage to cancer cells toevade the immune system¹². These cells are specialized in blocking Tcell function by promoting the expansion of T_(Reg) cells, depriving Tcells of essential amino-acids, producing oxidizing molecules (e.g. H₂O₂and ONOO⁻), and blocking T cell recruitment to tumors¹³. As mostcancers, colon cancer is also characterized by the infiltration withimmune cell types (e.g. T cells)¹⁴. However, because of MDSCs, thesecells are dysfunctional. Therefore, interfering with the function and/orrecruitment of MDSCs might provide tremendous benefit to strategiestargeting cancer cells, representing an attractive strategy to treat notonly colon cancer but also many others. Our data suggest that MDSCs arehighly sensitive to PARP-1 inhibition and thus can be targeted with lowdoses of PARP inhibitors. These findings are highly significant becausethey provide a potential solution that can benefit not only patientswith colon cancer but also those with other types of cancers usingFDA-approved PARP inhibitors at low doses. This approach would certainlyeliminate the possibility of drug resistance and enhance the efficacy ofmany existing and future immunotherapies.

(b) Innovation

Current therapeutic strategies aim at maximally inhibiting PARP, such aswith high doses of PARP inhibitor compounds. Embodiment as describedherein, which use low doses of the drugs to target MDSCs whilepreserving the function of cancer-killing immune cells, are novel andrepresent a paradigm-shifting concept.

(c) Results

Partial PARP-1 inhibition is sufficient to block expression ofinflammatory genes in primary colon epithelial cells (CECs) upon LPS orTNF exposure. We developed a highly reproducible method to isolate CECsfrom mice^(15, 16) and humans. FIG. 14(A) shows thesquare/hexagonal-shaped cells indicative of the epithelial nature of thecells (additional characterization of cells is described in ¹⁶). FIG.14(B) shows that PARP-1 heterozygosity reduces PARP-1 expression by ˜50%compared to that of WT cells^(7, 17). PARP-1 heterozygosity was aseffective as KO in reducing TNF, IL-6, and ICAM-1 in response to LPS(FIG. 14(C)) or TNF (FIG. 14(D)) as assessed by qRT-PCR.

Partial PARP-1 inhibition by gene heterozygosity is more efficient thanKO at reducing chronic inflammation-driven colon tumorigenesis in micedespite an equal modulation of systemic inflammation. A singleadministration of the carcinogen azoxymethane (AOM) to animals incombination of 4 cycles of treatment with 2% dextran sulfate sodium(DSS) is a reliable chronic inflammation-induced colon cancer model. Asingle dose of AOM (FIG. 2A and ^(18, 19)) or the 4 cycles of DSStreatment are insufficient to induce tumorigenesis ²⁰. AOM/DSS treatmentinduced ˜7-8 tumors in colons of WT mice (FIG. 15(A)). This burden waslower in PARP-1^(−/−) counterparts but, surprisingly, much lower inPARP-11^(+/−) mice. The tumors from AOM/DSS-treated PARP-1^(−/−) micewere not different from those of similarly treated WT mice (FIG. 15(B)). High PCNA immunoreactivity (a marker of cell proliferation) wasdetected in tumors of AOM/DSS-treated WT and PARP-1^(−/−) mice, whichwas much lower in tumors of treated PARP-1^(+/−) mice (p<0.001; FIG.27). FIG. 15(D) shows that the colonic mucosa was almost completelyabsent in affected areas. However, the mucosa of AOM/DSS-treatedPARP-1^(+/−) or PARP-1^(−/31) mice showed some disorganization andinjury, but the colonic crypts were relatively intact or in the processof recovery. The results on colitis are consistent with ²¹. The effectsof PARP-1 inhibition on the tumor burden mirrored a decrease in systemicinflammation (FIG. 15(E)). These results show that there are benefits topartially inhibiting PARP-1 and support the notion that aiming atcompletely inhibiting the enzyme with high doses of PARP inhibitors (innon-BRCA-deficient cancers) may not provide an important clinical valueand may become detrimental in the long run.

Partial inhibition of PARP-1 by gene heterozygosity protects againstAPC^(Min)-induced tumor burden in mice while complete inhibition by geneKO aggravates it. We next examined the effect of PARP-1 gene dosage onAPC^(Min)-induced intestinal tumorigenesis. We generated C57BL/6PARP-1^(+/31) and PARP-1^(−/−) mice²² in the APC^(Min/+) background(FIG. 21(A)). PARP-1 heterozygosity provided a remarkable protectionagainst the tumor burden (FIG. 21(B)). Surprisingly, PARP-1 KO not onlydid not protect against the tumor burden, it significantly aggravatedit. FIG. 21(C) shows that PARP-1 heterozygosity completely blocked thegeneration of large tumors (>4 mm) with a significant concomitantdecrease in small and middle size tumors. Conversely, PARP-1 KO promotedan increase in the number of small tumors. Weight loss observed in theAPC^(Min/+) mice was prevented by PARP-1 heterozygosity but not KO (FIG.28). PCNA immunoreactivity in tumors of APC^(Min/+) mice with WT orPARP-1 KO was not different (FIG. 21(D)); but, the difference betweenthese 2 groups and that of PARP^(+/−) mice was highly significant(p<0.01). Paradoxically, intra-tumoral inflammation (VCAM-1 and COX-2;FIG. 21(D) and FIG. 21(E)) was equally reduced in tumors of PARP-1^(−/+)and PARP-1^(−/−) mice.

PARP inhibition with a low dose of olaparib (Lynparza™) is protectiveagainst APC^(Min)-induced tumor burden in mice while a higher dose ofthe drug is not. We next examined the effect of a low dose (5 mg/kg) anda five times higher dose (25 mg/kg) of olaparib starting at 8 week ofage on APC^(Min)-driven tumorigenesis. FIG. 22(A) shows that althoughPARP inhibition with the low dose of olaparib provided a good protectionagainst the tumor burden, the higher dose showed high variability butoverall it provided no protection against the burden. In fact, some miceshowed a tumor burden that was higher than that of the vehicle group.The differential effects of the two doses of olaparib on the tumorburden were mirrored by respective effects on cachexia (FIG. 22(B)). Theresults are relatively consistent with the differential effects attainedusing the genetic approach. Note that most, if not all, studiesexamining the effects of olaparib on carcinogenesis using preclinicalmodels have used doses as high as 300 mg/kg/day. We are confident thathigher and more frequent doses of olaparib would aggravate the tumorburden in our experimental model.

PARP-1 inhibition genetically (by gene heterozygosity or KO) or byolaparib is effective at blocking systemic inflammation in APC^(Min/+)mice. Chronic inflammation exists in APC^(Min)-driven intestinalcarcinogenesis (FIG. 23) and²³⁻²⁵. All forms of PARP-1 inhibition wereable to significantly reduce IL-6 and TNF albeit not to the level ofcontrol mice. MCP-1 levels were significantly reduced by PARP-1inhibition to levels similar to those of WT controls. These resultsdemonstrate that PARP-1 inhibition promote an anti-inflammatoryenvironment.

PARP-1 inhibition provides a tumor-suppressive environment in MCA-38cell-based allograft model of colon cancer. Given the above results, itbecame critical to determine whether PARP-1 plays a role in the hostresponse to tumor development. We took advantage of an allograft modelusing the colon adenocarcinoma cell line MCA-38 (from a C57BL/6 mouse),which is WT for PARP-1 (FIG. 24(A)). FIG. 24(B) and FIG. 24(C) show thatgrafting of MCA-38 cells onto WT mice leads to formation of large solidtumors; these tumors were significantly smaller when grafted ontoPARP-1^(+/−) or PARP-1^(−/−) mice. The anti-tumor effects of PARP-1 geneheterozygosity and KO were accompanied by an efficient reduction insystemic (FIG. 24(C)) and intratumoral (FIG. 24(D)) inflammation as wellas reduced CD68⁺inflammatory cell recruitment (FIG. 24(E)).

PARP-1 plays a role in MDSC function and its partial PARP-1 inhibitionis sufficient to block the suppressive activity of these cells withoutaffecting the function of dendritic cells. Since PARP-1 seems to play animportant role in the host response to tumor formation, it may influencethe function of MDSCs. To test this, we isolated MDSCs from MCA-38cell-based tumors (by enzymatic digestion+purification using EasySepMouse CD11b Positive Selection). Purity of MDSCs was verified by FACSfor CD11b and Gr-1 positivity. MDSCs isolated from tumors of WT micewere very effective at suppressing T cell proliferation upon stimulation(FIG. 25(A)). Interestingly, MDSCs derived from tumors of PARP-1^(+/−)or PARP-1^(−/−) mice almost completely failed to suppress theproliferation of these WT T cells. Note that PARP-1 gene heterozygositywas sufficient to impair the function of MDSCs suggesting that they arevery sensitive to PARP-1 inhibition.

Also note that PARP-1 inhibition does not modulate indiscriminately allimmune cells as it has little to no effect on CD4⁺T¹¹, CD8⁺T²⁷, NK²⁷, ordendritic (DCs) (FIG. 25(B)) cell populations. We acknowledge thatAldinucci et al.²⁸ reported a role for PARP in DC maturation; thisconclusion was reached using unreasonably high doses of PARP inhibitors(TIQ-A) (20-30 μM), which we showed to be cytotoxic²⁹.

Low concentrations of olaparib are more effective than highconcentrations in blocking MCA-38-based tumors in WT mice. Given theabove results, we next speculated that low doses of PARP inhibitors(e.g. olaparib) might be more beneficial than high doses inimmunocompetent mice. To this end, WT mice were engrafted with MCA-38cells and as soon as the tumors were palpable (day 6), mice received0.2, 1, or 5 mg/kg olaparib or vehicle. Mice that received vehicleincreased in size in a time-dependent manner and were sacrificed at day16. The tumors in mice that received 5 mg/kg olaparib were relativelysmaller than those of WT. Remarkably, the tumors in mice that receivedthe lowest dose of olaparib barely increased above the size the tumorsat the day 5. The middle dose (1 mg/kg) were very effective at blockingtumor growth; at 16 growth was more visible. These results are extremelyimportant because they provide an unexpected and a novelparadigm-shifting concept with high clinical relevance. These resultsmay also explain why high doses of PARP inhibitors failed to beefficacious against several cancers with no BRCA mutation.

(1) To decipher the relationship between PARP-1, its inhibition bydecreasing doses of olaparib, and MDSCs differentiation, intra-tumoralrecruitment and function using the MCA-38 cell-based allograft model.

1. To determine the effects of PARP inhibition on the recruitment ofMDSCs using the allograft model. PARP-1 appears to play a role in MDSCfunction and, without wishing to be bound by theory, this effect mayaccompany a decrease in MDSCs recruitment to the tumors. For example,PARP-1 inhibition may affect the recruitment of the cells given ourreported connection between PARP-1 and CXCR2³⁰, a receptor required fortrafficking to tumors³¹.

Specific Experiment 1. MCA-38 cells will be engrafted onto mice as shownin FIG. 24. Tumors will be collected from sacrificed mice on day 15 (orwhen the size of the tumors is large enough to isolate MDSCs in allgroups). Portions of the tumors and spleens will be digested to generatesingle cell suspension. Cells will be assessed for MDSC numbers by FACSwith fluorescently labeled antibodies to CD11b, Ly6G (Gr1), or Ly6C. Thetwo latter markers will allow us to determine whether the recruitedMDSCs are granulocytic (GrMDSCs) (CD11b)⁺, Ly6G^(+high), Ly6C^(low)) ormonocytic (MoMDSCs) (CD11b⁺, Ly6C^(30 high), Ly6G). Recruitment will beassessed as percent MDSCs of the total number of isolated cells. Giventhat percentages can be misleading and that the tumor size betweengroups could be very different, we will correct the numbers according totumor volume. We will also assess the single cell suspension for theprevalence of cytotoxic CD8^(⊐) T-cell populations (IFNγ⁺CD8⁺CD3⁺CD45⁺).MDSCs from all groups will also be isolated as described above andsubjected to RNA extraction followed by quantitative RT-PCR using primersets for iNOS and Argl.

Specific Experiment 2. To determine whether the tumor microenvironmentinfluenced the differences we may see in the above experiment, a portionof the tumor will be subjected to RNA extraction followed byquantitative RT-PCR using primer sets specific for CXCR2 or CXCR4,GM-CSF, G-CSF, IL-4, IL-6, IL-13, TNF, TGFβ and several others.

2. To determine whether low doses of olaparib prevent tumor progressionby decreasing the recruitment of MDSCs in the allograft model.

Specific Experiment 1: We will repeat the experiment described in FIG.20 with two major alterations: 1) we will keep measuring tumor sizes fora longer period even after the termination of the groups receivingvehicle. This will allow us to have a better idea on how long the effectof the low doses of olaparib can maintain their effects on tumorprogression. 2) We will also determine the lowest dose of the drug thatcan modulate tumor progression in our allograft model. We will continueusing a de-escalation of the doses by five-fold increments as describedin FIG. 20.

Specific Experiment 2: While conducting experiment 1, we will assign agroup of mice to be sacrificed at day 15 to conduct the same assaysdescribed herein, such as in Goal 1.

3. To determine the role of PARP-1 and the effect of olaparib ondifferentiation of MDSCs ex vivo. The results of goal 1 may notdifferentiate between the effects on MDSCs, other immune cells, andcancer cells. It is, thus, important to determine whether PARPinhibition affects directly differentiation of MDSCs. This becomes evenmore important when we consider the fact that olaparib as well as otherPARP inhibitors affect both PARP-1 and PARP-2. We intend to examinewhether PARP-1 expression and/or activity affect differentiation ofMDSCs from BM progenitors.

Specific Experiment 1. BM cells will be harvested from WT, PARP-1^(+/−),or PARP-P′⁻ as in ¹⁰, which will then be cultured with G-CSF, GM-CSF,and IL-6 ³². MDSCs will be assessed by FACS for numbers and subtypes.MDSCs will also be positively selected to assess their T-cellsuppression capacity and their ability to express iNOS and Argl byRT-PCR.

Specific Experiment 2. A portion of WT or PARP-P^(+/−) BM cells will becultured in the presence of 1, 0.2, 0.04 μM olaparib (at day 0 and day2). Again, PARP inhibitors may affect PARP-1 and PARP-2 and thus itbecomes important to examine whether the effects of olaparib areassociated solely with PARP-1 or may also be related to PARP-2. Toaddress this, we will treat PARP-P^(−/−) BM cells with olaparib as willbe done for WT cells. MDSCs from all conditions will be subjected toFACS analysis, purification, T cell suppression capacity, and RT-PCR foriNOS and Arg1.

4. To determine whether partial or complete depletion of PARP-1 incancer cells affects recruitment of MDSCs to tumors in the allograftmodel. We will next address whether PARP-1 plays a role in the abilityof tumors to influence MDSC recruitment and activation. We will useshRNA and CRISPR/cas9 approaches on MCA-38 cells for partial andcomplete depletion, respectively, in a manner similar to that achievedin A549 cells (FIG. 26). Partial knockdown would mimic PARP-1heterozygosity and deletion with CRISPR/Cas9 would mimic PARP-1 KO.

Specific Experiment. MCA-38 cells that were subjected to partialknockdown (MCA38-PARP-1^(shRNA)) and those to CRISPR/Cas9(MCA-38-PARP-1^(CRISPR/Cas9)) will be engrafted with their respectivecontrols onto opposing flanks of WT mice. Tumor volumes will be assessedas in FIG. 24. At day 15 (or when the size of the tumors is large enoughto isolate MDSCs in all groups), tumors will be harvested aftersacrificing the mice. The tumors will be divided into equal portions byweight. A portion will be digested to generated single cell suspensions,which will be assessed for MDSCs populations by FACS or for MDSCisolation by positive selection to assess their T-cell suppressioncapacity or their ability to express iNOS and Argl. The second portionof the tumors will be assessed for CXCR2 or CXCR4 and a number ofinflammatory factors (described in Goal 1 of Aim 1) to determinewhatever difference we see between the groups can be attributed to theability of the cancer cells to produce the factors that are critical forMDSC recruitment and activation.

(2) To examine whether myeloid-specific or colon epithelial-specificdeletion of PARP-1 influences tumorigenesis and MDSC trafficking in amouse model of APC^(Min)-driven colon cancer.

Using spontaneous models will provide us with critical information thatis of great relevance to the human condition. For the following studies,we have several options, which include different models of colon cancerrepresenting the many aspects and complexity of the human disease. Ourlab is very well versed in the APC^(Min/+) mouse model. APC genemutations are attributed to cases of familial adenomatous polyposis(FAP) as well as approximately ˜70% of sporadic colorectal cancel³³⁻³⁵.We are also versed with a colon cancer model that is exclusively inducedby repeated administrations of the carcinogen DMH¹⁶ or its metaboliteAOM. We also have the AOM/DSS model that is induced by chronic coloninflammation (FIG. 15). We will focus on the APO^(Min) model because ofits simplicity; however, we can use any of these models as needed, whichaltogether encompass many aspects of human colon cancer. We will use ournew PARP-1-floxed mice under different Cre-strains. The mutant strainwas generated (germ line transmission and Neo cassette removal) byCyagen. We will be crossing the mutant mice with several Cre-strains. Wesucceeded in generating the floxed-PARP-1 under the control of Tek-Cre(FIG. 10) and termed PARP-1^(Tek-fl/wt) and PARP-1^(Tek-fl/fl) forheterozygous and KO, respectively. We should complete the generation oftermed PARP-1^(CDX2-fl/fl) strain rather shortly. These strains willthen be crossed with APO^(Min) as in FIG. 21.

1. To examine whether myeloid-specific PARP-1 gene heterozygosity or KOreduces APC^(Min)-induced tumor burden and determine whether it altersintra-tumoral MDSC trafficking and function.

Specific Experiment. APC^(Min/+)/PARP -1^(Tek-fl/wt) andAPC^(Min/+)/PARP-1^(Tek-fl/fl) mice will be sacrificed at 16 wks of age;we will use the APC^(Min/+)/PARP-1^(fl/fl) littermates as WT PARP-1animals. The tumor burden in the intestinal track will be assessed(numbers and sizes) as described in FIG. 21. Tumors will be collectedand subdivided according to their position in the intestinal track. Twothird of the tumors and spleens will be digested for single cellsuspension. The remaining portion will be processed for RNA and DNAextraction. A small portion of the single suspensions will be assessedby FACS analysis for the number and subtypes of MDSCs. The remainingwill be used for MDSC isolation as described above. Isolated MDSCs willbe assessed for their T cell suppression capacity or for RNA extractionto assess the expression levels of iNOS and Arg1. Extracted RNA(directly from the tumors or spleens) will be assessed by qPCR withprimer sets specific for CXCR2 or CXCR4 and a number of inflammatoryfactors (described in Goal 1 of Aim 1).

2. To examine whether colon epithelial cell-specific PARP-1 geneheterozygosity or KO alter Apc^(Min)-induced tumor burden by influencingMDSC trafficking and function within the tumor microenvironment.

Specific Experiment. APC^(Min/+)/PARP-1^(fl/fl),APC^(Min/+)/PARP-1^(CDX2-fl/wt), APC^(Mini/+)/PARP-1^(CDX2-fl/fl) micewill be sacrificed at 16 wks of age and processed the same way asdescribed in Goal 1, above.

3. To examine the potential differential effects of colon epithelialcell-specific PARP-1 gene heterozygosity and KO on Apc^(Min)-inducedtumor burden is associated with changes in genomic instability in tumorcells. We believe that the primary reason for PARP-1 gene KO foraggravating the tumor burden in APC^(Min/+) mice is the accumulation ofgenomic instability in addition to that induced by the APC^(Min)mutation.

Specific Experiment. DNA extracted from the tumors of the differentexperimental groups will be assessed by aCGH essentially as done in ourpublished report¹⁶. The samples will be analyzed using the Agilent DNAmicroarray platform. Data including Copy Number Variations will beassessed by Agilent Feature Extraction software 12 and analyzed withAgilent Genomic Workbench software 7.0 using the statistical algorithmsz score.

Expected outcomes: Without wishing to be bound by theory, we expect thatpartial PARP-1 inhibition would be effective in reducing the recruitmentof MDSCs and their function. It is rather possible that low doses ofolaparib block the function of MDSCs but not their recruitment. Thesepotential differential effects are likely given our previous findingsshowing that low doses of olaparib interferes with T cell-response toCD3/CD28-stimulated production of Th2 inflammatory factors withoutaffecting the signal leading to their proliferation¹¹. We may alsoexpect that inhibition of PARP in MDSCs may change their phenotype toacquire an anti-tumor trait in a manner similar to that observed whenChop protein was depleted in MDSCs³⁸. This is based on the finding (FIG.30) that PARP-1 inhibition decreases Chop expression in CD68⁺ cells inresponse to oxidized cholesterols.

The effects of PARP-1 inhibition may be even more enhanced if itsefficiency in increasing the efficacy of adoptive T cell and checkpointblockade (e.g. PD-1 or PD-L1)-based therapies is examined. Clinical³⁹and preclinical trials⁴⁰ have looked into the combination of PARPinhibitors and anti-PD1 therapy but again using high daily doses of thedrugs or immunodeficient mice. In some studies, the dose of the PARPinhibitor was as high as 300 mg/kg/day, which is unreasonable andcertainly nontherapeutic, as these high doses can be extremely toxic toall cell types including the cancer cells themselves. We believe thathere resides the novelty of our hypothesis.

Without wishing to be bound by theory, we expect that the tumor burdento be significantly lower in both PARP - 1^(Tek-fl/wt) andPARP-1^(Tek-fl/fl) mice compared to the PARP-1^(fl/fl) (on Apc^(Min)background) controls. This is based on the potential that myeloid cellsthat are partially or completely deficient in PARP-1 would be unable toinduce inflammation even if the tumor cells would produce inflammatorycues. The associated MDSCs would also be incapable of suppressing Tcells. It is possible that PARP-1 KO may have some effect on T cellfunction and if this possibility presents itself, we believe thatAPC^(Min/+)/PARP-1^(Tek-fl/fl) mice would have a higher tumor burdenthan that of APC^(Min/+)/PARP-1^(Tek-fl/wt) mice but would besignificantly less than that of the APC^(Min/+)/PARP-1^(fl/fl) controls.As for the APC^(Min/+)/PARP-1^(CDX2-fl/wt) mice, it would be difficultto predict the outcome. If we consider that the complete absence ofPARP-1 in CECs would prevent the production of inflammatory factorsnecessary for MDSC recruitment; these same cues may be necessary forrecruiting cytotoxic T cells. The net outcome would depend on the effectof PARP-1 gene deletion on the cancer cell. If high genomic instabilityis reached, then one would expect to observed high incidence of tumors(size and/or numbers) in the colon while the tumor burden in the smallintestine would remain the same as in the control mice.

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Example 4

Use of Low Doses of PARP Inhibitors as Adjuvant Therapy forImmunotherapeutic Approaches and Treatment Strategies that do not TargetDNA Repair/Damage Mechanisms

PARP inhibitors such as olaparib (LYNPARZA™) and others (under clinicaltrials) are used to target cancer cells with deficiencies in DNA repairenzymes (e.g. BRCA mutations) with a goal to achieve synthetic lethality(specific death of cancer cells) . Our results show that partial PARPinhibition is very effective at reducing cancer-related inflammation andpromoting a tumor-suppressive environment by interfering with the tumorpromoting activity of MDSCs. Without wishing to be bound by theory, onecan use PARP inhibitors at a dose that can be gaged according cancertype and affected patient to achieve a better clinical outcome withimmunotherapy approaches or with therapies whose targets do not includeDNA repair/damage enzymes.

The PARP inhibitor olaparib (LYNPARZA™) is currently being used as anoral treatment for women with BRCA-mutated advanced ovarian cancer;other PARP inhibitors are under clinical trials for other cancers withDNA repair deficiency. As described herein, PARP inhibitors, at lowdoses, can be used to increase the efficacy of immunotherapy approachesand other approaches that do not target DNA repair/damage enzymes. SeeFIG. 31, for example. Thus PARP inhibitors can be used for the treatmentof a variety of cancers that can benefit from immunotherapy.

The current concept in the use of PARP inhibitors is to achieve maximalinhibition of the enzyme (PARP) with synthetic lethality (i.e . death ofmutated cancer cells) as the ultimate goa 1. Embodiments as describedherein enhance the immune system in such a way to improve the efficacyof immunotherapy or approaches that do not target DNA repair/damageenzymes in fighting cancer. An additional but important aspect with thisapproach is that low doses of the drugs may lead to fewer side effects.

Example 5

Metronomic Therapy Targeting Myeloid-Derived Suppressor Cells with thePARP Inhibitor Olaparib Enhances Anti-PD1 Immunotherapy in Colon Cancer

Focusing on the maximum-tolerated-dose of PARP inhibitors (PARPi)detracts from reaping the benefits of targeting DNA repair-independentaspects of PARP with lower drug doses. Here, we show that partial PARP-1inhibition via gene heterozygosity or a moderate olaparib dose protectedagainst colitis- or APC^(Min)-mediated intestinal tumorigenesis, whileextensive inhibition via gene knockout or a high olaparib dose wasineffective despite anti-inflammatory effects and promotion of atumor-suppressive microenvironment. A sub-IC50 metronomic dose ofolaparib was sufficient to block tumorigenesis in syngeneic colon cancermodels by modulating the T-cell suppressive function, but notintratumoral migration, of myeloid-derived suppressor cells (MDSCs) viaa reduction of arginase-1/iNOS/COX-2 expression but independently ofPARP-1-trapping on chromatin. A metronomic olaparib dose exhibitedremarkable synergy with anti-PD1-based immunotherapy in mice. Theseresults indicate that targeting MDSCs with metronomic PARPi dosesenhances efficacy of immunotherapies, validating a paradigm-shift thatexpands the utility of PARPi in anti-cancer therapy.

Introduction

PARP inhibitors (PARPi) are emerging as a promising therapy for ovarianand breast cancers as well as potentially for a few other cancers thatmay be driven by deficiencies in non-PARP-associated DNA repair (1).Interestingly, a number of clinical trials demonstrated the efficacy ofPARPi in the treatment of other cancers with no obvious mutations in theBRCA1 gene (2). These observations clearly suggest a potential for thistherapeutic strategy to be utilized in non-BRCA1 mutated cancers.Unfortunately, many of these trials fail to advance to actual therapies.Olaparib was tested in phase I (3) and phase II (4) clinical trials onpatients with advanced colon cancer as a monotherapy or in combinationwith irinotecan (Camptosar) with disappointing results but withrecommendations for more comprehensive studies. Without wishing to bebound by theory, the primary reason for the failure of PARPi in treatingnon-BRCA1 mutated cancers is the fact that the intricacies of the roleof the enzyme in cancer pathogenesis are not fully understood. This ideabecomes even more important when considering that the cancermicroenvironment is not only influenced by the neoplastic cell but alsoby structural and cellular components that include immune cells.Important objectives of our laboratory are to unravel unobviousfunctions of DNA repair enzymes, such as PARP-1, and to validate thatthese enzymes play critical roles not only in cancer cell-relatedprocesses (e.g. DNA repair, cell death, and genomic integrity) but alsoin inflammatory and immune responses. The function of PARP-1 in cancersmay be intimately related to its ability to provide an alternativepathway for cancer cells to survive, especially for those cancersassociated with defects in DNA repair; however, the mechanism by whichPARP-1 contributes to inflammation and immune responses may be verydifferent.

The role of PARP-1 in DNA repair requires the full activity of theenzyme, as partial inhibition of PARP-1 is not associated with majordefects in DNA repair (5). Indeed, PARP-1 heterozygous cells or micerespond similarly to DNA-damaging agents as their wild-type (WT)counterparts (5, 6). Interestingly, we reported that PARP-1heterozygosity, which reduces PARP-1 by ˜50%, or a metronomic dose ofPARPi substantially blocked atherosclerosis in high-fat diet-fedApoE^(−/−) mice and asthma in allergen-exposed mice (7-9). Inhibition ofPARP with 3-aminobenzamide, an old-generation weak inhibitor, was shownto provide protection against trinitrobenzene sulfonic acid-inducedcolitis in rodents and in an interleukin (IL)-10 deficiency-based mousemodel of chronic intestinal inflammation (reviewed in (10)), whilecomplete inhibition of PARP-1 by gene knockout enhanced tumorigenesis toazoxymethane-induced colon tumorigenesis (11). In vitro studies from ourlaboratory revealed that an olaparib concentration that does not affectproliferation of human CD3⁺ T cells was very effective at reducingexpression of Th2-associated genes, while sparing such effects on IFNγexpression (9). Furthermore, while a moderate concentration (1 μM) ofolaparib did not induce an increase in the CD25^(+/)Foxp3⁺ Treg cellpopulation upon stimulation of CD4⁺ T-enriched cells with antibodies toCD3/CD28, a higher concentration (5 μM) almost doubled the percentage ofthese regulatory cells. Altogether, these reports clearly suggest thatlow-to-moderate doses of PARPi may have completely different effectsthan those mediated by high doses of the drugs.

One of the hallmarks of tumor progression and resistance to therapy isthe recruitment of myeloid-derived cells that suppress cancercell-killing immune cells. Myeloid-derived suppressor cell (MDSC)recruitment and expansion represent critical events during cancerprogression, which can be classified as granulocytic orpolymorphonuclear (G- or PMN) or monocytic (M)-MDSCs. While PMN-MDSCsresemble neutrophils, M-MDSCs display more monocytic-like traits (12,13). These cells provide an advantage to cancer cells, allowing them toevade the immune system (12). MDSCs are specialized in blocking T-cellfunction by promoting the expansion of Treg cells, depriving T cells ofessential amino-acids through expression of arginase (ARG)-1, producingoxidizing molecules (e.g., ONOO⁻) through the expression of induciblenitric oxide synthase (iNOS), and blocking T-cell recruitment to tumors(12). Therefore, it is clear that interfering with the function and/orrecruitment of MDSCs may provide important benefits to strategiestargeting cancer cells, representing an attractive strategy to treat notonly colon cancer but also many other cancers.

Most current therapeutic strategies rely heavily on the administrationof chemotherapeutic agents based on the maximum-tolerated-dose (MTD)paradigm, even when combined with adjuvant therapies; however, such aphilosophy misses the potential of metronomic regimens aimed at the sameor alternate targets that may be of equal or greater benefit (14, 15). Aprimary goal of the current study was to compare the effects of partialPARP inhibition by gene heterozygosity or a low-to-moderate dose ofolaparib provided in a metronomic manner to complete or extensiveinhibition of the enzyme by gene knockout or high-dose olaparib oninflammation-driven or spontaneous colon cancer. We also sought toexamine whether the different approaches exert different immuneresponses to carcinogenesis by focusing primarily on MDSCs and determinewhether a metronomic dose of olaparib synergizes with anti-PD1immunotherapy.

Results

Partial PARP-1 Inhibition is More Efficient than Complete Inhibition atReducing Chronic Inflammation-Driven Colon Tumorigenesis in mice Despitean Equal Modulation of Systemic Inflammation

PARP-1 gene heterozygosity reduced PARP-1 expression by ˜50% compared tothat of WT cells (FIG. 32A), which is consistent with our previousreport (8) and is known to lead to an equal reduction in enzymaticactivity (16). Using a method for colon epithelial cell (CEC) isolationfrom mice developed by our laboratory, we compared the efficacy ofpartial PARP-1 inhibition by gene heterozygosity in reducinglipopolysaccharide (LPS)- or tumor necrosis factor (TNF)-α-inducedexpression of inflammatory genes with that of complete inhibitionachieved by gene knockout. FIG. 32B shows that the potent capacity ofLPS to induce expression of IL-6, TNF-α, iNOS, intercellular adhesionmolecule (ICAM)-1, and vascular cell adhesion molecule (VCAM)-1 in WTCECs was significantly reduced in similarly treated PARP-1^(+/−) andPARP-1^(−/−) CECs. Remarkably, PARP-1 heterozygosity was as effective asknockout at reducing or blocking the expression of the examined genes.In response to TNF-α, PARP-1 heterozygosity was either equally effectiveor even better than knockout at reducing expression of the adhesionmolecules ICAM-1 and VCAM-1, respectively (FIG. 32B). These resultsdemonstrate that complete inhibition of the enzyme is not necessary toachieve maximal blockade of inflammatory responses.

We next examined whether PARP-1 gene dosage exerted similar effects oninflammation-driven colon cancer. To this end, we selected a coloncancer model that is exclusively induced by chronic inflammation via asingle administration of the rodent carcinogen azoxymethane (AOM) tomice followed by four cycles of dextran sulfate sodium (DSS) in drinkingwater. Notably, neither administration of AOM nor DSS was sufficient toinduce tumorigenesis (FIG. 32C). The AOM/DSS combination is highlyconsistent in inducing primarily colon tumors ((17) and FIG. 32D), andthis AOM/DSS treatment regimen induced an average of 8-10 tumors incolons of WT mice. AOM/DSS-treated PARP-1⁻¹⁻ mice displayed asignificantly (p<0.001) lower tumor burden than similarly treated WTmice, consistent with a recent report by Dorsam et al. (18).Surprisingly, partial PARP-1 inhibition generated by gene heterozygositywas far more effective than gene knockout at reducing the tumor burden(p=0.0063). Overall, the tumors detected in all experimental groups weresmall (˜2 mm in diameter), reaching adenoma or adenocarcinoma status (>1mm) only in AOM/DSS-treated WT and PARP-1^(−/−) mice. Examination oftissue sections prepared from the colons of AOM/DSS-treated WT miceshowed rather typical colon tumors with marked hyperplasia and dysplasiaand development of large aberrant crypt foci (ACF), which were notdrastically different from those of similarly treated PARP-1^(/) mice(FIG. 32D). Interestingly, the tumors from AOM/DSS-treated PARP-1^(+/−)mice were markedly smaller and consisted primarily of large ACFs. Highimmunoreactivity to PCNA, a marker of cell proliferation, was detectedin tumors of AOM/DSS-treated WT and PARP-1^(−/−) mice (FIG. 32E), andthis immunoreactivity was much lower in tumors of treated PARP-1+^(+/−)mice (p<0.001; FIG. 38). AOM/DSS treatment-induced damage to the colonicmucosa in PARP-1+/− and and PARP-1^(−/−) mice was not as prevalent asthat observed in similarly treated WT mice (FIG. 32F). It is noteworthythat the mucosa of AOM/DSS-treated PARP-1^(+/−) or PARP-1^(−/−) (niceshowed some disorganization and injury, but the colonic crypts wererelatively intact or appear to be in the process of recovery. Theseresults are consistent with those reported by Larmonier et al. (19) inwhich PARP-1^(−/−) mice were found to be resistant to DSS-based colitisinduction.

Given the clinical relevance of our studies, we then sought to examinewhether pharmacological inhibition of PARP with olaparib prevents orreduces colon tumorigenesis in the AOM/DSS mouse model of colon cancer.It is noteworthy that olaparib inhibits both PARP-1 and PARP-2, andtherefore, specificity to PARP-1 in our studies is always based on thecommon results between those attained with the drug and those attainedin PARP-1^(+/−) or PARP-1^(−/−) mice. To conduct this study, we electedto use a moderate olaparib dose of 5 mg/kg to be consistent with ourprevious studies in addition to an olaparib dose that is five timeshigher (25 mg/kg), which is a beginning dose in most publishedpreclinical cancer studies (10). The drug was administered twice weeklyfor the duration of the protocol. FIG. 32G shows that treatment witholaparib at either dose significantly reduced the tumor burden comparedto treatment with the vehicle. When colonic mucosa was examined forevidence of colitis in the two groups, olaparib treatment provided anotable protection against AOM/DSS treatment-induced effects (FIG. 32H).These results are in agreement with those attained using AOM/DSS-treatedPARP-1^(+/−) and PARP-1^(−/−) mice, indicating that PARP inhibition,partially or completely, is effective at blocking colitis. As statedabove, the AOM/DSS colon cancer model is driven primarily by chronicinflammation; thus, we next assessed mice sera for inflammatory factorsTNF-α, IL-6, and MCP-1, which are highly relevant to human coloncarcinogenesis. FIG. 321 shows that all forms of PARP-1 inhibition wereassociated with a marked reduction in the levels of TNF-α and MCP-1 witha moderate effect on IL-6 levels. These results indicate that the roleof PARP-1 in colon inflammation may, in part, constitute the underlyingmechanism by which the enzyme participates in the pathogenesis of coloncancer.

Partial inhibition of PARP-1 by gene heterozygosity or a moderate doseof olaparib protects against APC^(Min)-induced tumor burden in micewhile complete inhibition by gene knockout aggravates tumor burden

If chronic inflammation is the sole mechanism by which PARP-1participates in colon tumorigenesis, then the ability to severely blockinflammation upon inhibition of the enzyme, pharmacologically orgenetically, should almost entirely alleviate the tumor burden.According to the above data, however, this is not the case. Therefore,we next examined the role of PARP-1 gene dosage on colon tumorigenesisusing the APC^(Min/+) mouse model, which spontaneously developsintestinal tumors but does not exclusively rely on inflammation. Ingeneral, APC^(Min/+) mice have a rather short lifespan and often die notonly as a result of tumor burden but also due to development of severeanemia, substantial cachexia, and/or intestinal intussusceptions. Tothis end, C57BL/6 PARP-1^(+/−) and PARP-1^(−/−) mice were generated inthe APC^(Min/+) background (FIG. 39). PARP-1 heterozygosity providedremarkable protection against tumor development (FIG. 33A).Surprisingly, PARP-1 knockout not only failed to provide any protectionbut actually significantly aggravated the tumor burden. In addition,PARP-1 heterozygosity completely blocked the generation of large tumors(>4 mm in diameter) with a significant concomitant decrease in small andmedium-sized tumors (FIG. 33B). Conversely, PARP-1 knockout promoted anincrease in the number of small tumors. PCNA immunoreactivity in tumorsof APC^(Min/+) mice did not differ from that observed inAPC-^(Min/+)PARP-1^(−/−) mice (FIG. 33C), but the difference betweenthese two groups and that of PARP-1^(+/−) mice was highly significant(data not shown). Paradoxically, intratumoral inflammation as assessedby immunoreactivity to COX-2 (FIG. 33D) was equally reduced in tumors ofPARP-1^(+/−) and PARP-1^(−/−) mice. We next examined the effect ofadministration of a moderate (5 mg/kg) or a high (25 mg/kg) dose ofolaparib on APC^(Min)-driven tumorigenesis in mice starting at 6 week ofage. PARP inhibition from the moderate dose of olaparib provided goodprotection against tumor development; however, although the higher doseresulted in great variability in response, overall, it provided nosignificant protection with respect to tumor burden (FIG. 33E). In fact,some of the mice treated with the higher olaparib dose showed a greatertumor burden than that of the vehicle group.

Weight loss or cachexia is often observed in patients with colon cancerand is a persistent trait in the APC^(Min/+) mouse model of coloncancer. Indeed, APC^(Min/+) mice weighed ˜15-25% less than WT mice (FIG.33F), consistent with published reports (20). PARP-1 heterozygositycompletely prevented cachexia. Surprisingly, while PARP-1 knockoutaggravated the tumor burden in APC^(Min/+) mice, this genotype not onlyfailed to aggravate the weight loss observed in these mice but alsoactually prevented this weight loss to a small but statisticallysignificant level. While the moderate dose of olaparib protected againstcachexia in APC^(Min/+) mice, the high dose of the drug did not.Although splenomegaly is not a common feature in human colon cancer, itis a persistent trait ofAPC^(Min/+) mice and other mouse tumor models.FIG. 33G shows that, as expected, APC^(Min/+) mice displayed largerspleens that were often as much as 6× larger than that of a matched ageWT mice. Interestingly, all forms of PARP-1 inhibition reduced the sizeof spleens similarly, although control spleen sizes were not reached.Systemic inflammation is also a component of APC^(Min)-driven intestinalcarcinogenesis. All forms of PARP-1 inhibition significantly reducedMCP-1 to levels comparable to those detected in sera of WT mice (FIG.33H) but had more moderate effects on TNF-α levels. As for IL-6, onlyPARP-1 heterozygosity promoted a slight but statistically significantreduction in the cytokine. These results indicate that the protectiveeffects of PARP-1 heterozygosity or the moderate dose of olaparib is notstrictly associated with a reduction in systemic inflammation but isrelated, rather, to host response to such inflammation and tumordevelopment.

A metronomic dose of olaparib or PARP-1 gene heterozygosity aresufficient to promote a tumor-suppressive environment in the MC-38cell-based syngeneic colon cancer mouse model

It is noteworthy that the host immune response is recognized as animportant determinant of carcinogenesis in general and of colon cancerin particular (21). Given the above results, it became imperative todetermine whether PARP-1 plays a role in the host response to tumordevelopment. To this end, we took advantage of a syngeneic model basedon the colon adenocarcinoma cell line MC-38, which was derived from aC57BL/6 mouse. MC-38 cells express abundant levels of PARP-1 protein(FIG. 34A) and are expected to behave as WT cells. Engraftment of MC-38cells into the flanks of WT mice led to sizable solid tumors (FIG. 34B),while engraftment into either PARP-1 heterozygous or knockout micesignificantly reduced the size of the tumors at day 22. The tumorsgenerated in PARP-1^(+/−) and and PARP-1^(−/−) mice displayed littleinflammation compared to the WT counterparts as assessed by ICAM-1immunoreactivity (FIG. 34C). This reduction in tumor burden wasaccompanied by a maintenance of normal size spleens (FIG. 34D).

Because a moderate dose of 5 mg/kg olaparib provided superior protectioncompared to a high dose in the APC^(Min/+) mouse model, we elected tocontinue using the moderate dose but also examined the effects of a25-fold lower metronomic dose (i.e., 0.2 mg/kg). To this end, WT micewere engrafted with MC-38 cells, and when tumors were palpable, micewere administered either 0.2 or 5 mg/kg olaparib once every 2 days.Surprisingly, although the moderate dose of olaparib provided asignificant reduction in the size of MC-38 cell-based tumors, the lowerdose of the drug was more effective at reducing the tumor burden (FIG.34E). An evaluation of intratumoral ICAM-1 immunoreactivity as asurrogate for inflammation revealed that both doses promoted a reductionin inflammation (FIG. 34F). Systemic inflammation, as assessed by thelevels of TNF-α, IL-6, and MCP-1 in sera of animals, was moderatelyreduced by both doses of olaparib, despite the different outcomes on thetumor burden (FIG. 34G). Examination of protein extracts prepared fromtumors from the different experimental groups showed that all forms ofPARP inhibition tended to increase the levels of active caspase-3 and -7(FIG. 34H), indicating higher levels of cell death within those tumors.Overall, these results indicate that a low dose of olaparib can exert asuperior anti-tumor effect compared to a high dose, despite therelatively similar reduction in intratumoral and systemic inflammation.

PARP-1 plays a key role in MDSC function, and partial inhibition ofPARP-1 by gene heterozygosity or low-to-moderate doses of olaparib aresufficient to block the suppressive activity of these cells

Pro-tumor immune cells, such as MDSCs, are important players in theregulation of the tumor microenvironment via suppression of the hostresponses to tumors and promotion of tumorigenesis (12). We thereforeexamined whether partial PARP inhibition by olaparib treatment or geneheterozygosity affected this cell population in MC-38 cell-generatedtumors. The low dose (0.2 mg/kg) of olaparib did not significantlyaffect the percentages of CD11b⁺/Gr1⁺ MDSCs or their numbers in theexamined tumors (FIG. 35A & B). The moderate dose (5 mg/kg) of olaparib,however, significantly increased the numbers and percentages of M-MDSCs,albeit by a relatively small amount (FIG. 35C). PARP-1 heterozygosity,on the other hand, was associated with a minor but statisticallysignificant increase in the percentage of M-MDSCs with a concomitantdecrease in PMN-MDSCs; however, the overall cell numbers were comparableto those detected in tumors generated in WT mice (FIG. 35C). Only thelow dose of olaparib increased CD3⁺ T cells, and most of these were CD8⁺T cells (FIG. 35D). The intratumoral distribution of MDSCs (Gr1⁺) andCD8⁺ cells in the different experimental groups was corroborated usingimmunohistochemistry with antibodies to murine Gr1 or CD8 by apathologist (Dr. L. DelValle), who was blinded to the different groups(FIG. 35E). Interestingly, in the spleens, only the moderate dose ofolaparib promoted a substantial decrease in overall CD3⁺ T cells and aconcomitant decrease in CD8+ T cells (FIG. 35F), suggesting immunesuppressive effects.

The lack of a major effect of PARP inhibition on MDSC populationsindicates that the migration of these cells into the tumors was notdrastically affected by the different forms of PARP-1 inhibition tosufficiently explain the reduction in tumor burden. Without wishing tobe bound by theory, PARP-1 may influence the function rather than thephenotype of MDSCs. To test this, MDSCs were isolated from MC-38cell-generated tumors using CD11b positive selection and thenco-cultured with CFSC-labeled anti-CD3/CD28-activated WT T cells withoutthe addition of olaparib. As expected, MDSCs isolated from tumors of WTmice were effective at suppressing T-cell proliferation upon stimulation(FIG. 35G). MDSCs derived from tumors of olaparib-treated mice exhibiteda reduced capacity to suppress T-cell proliferation, and cells from micetreated with the moderate dose displayed a more pronounced effect.Remarkably, MDSCs derived from tumors of PARP-1^(+/−) mice completelyfailed to suppress the proliferation of WT T cells. MDSCs derived fromtumors of PARP-1^(−/−) mice also failed to suppress T-cell proliferationin vitro (FIG. 40). Altogether, these results suggest that PARP-1 playsa critical role in MDSC function and that these cells are very sensitiveto PARP-1 inhibition either with a low dose of olaparib or PARP-1heterozygosity.

A sub-IC50 concentration of olaparib is sufficient to reduce MDSCsuppressive function in vitro, in part, by blocking the expression ofARG-1, iNOS, and COX2, and the adoptive transfer of WT MDSCs abrogatesthe protective effects of PARP-1 heterozygosity against the tumor burden

We next explored the potential mechanism(s) by which even a low dose ofa PARPi reduces the function of MDSCs. To this end, bone marrow cellscollected from WT or PARP-1^(+/−) mice were incubated with a cocktailcontaining GM-CSF, G-CSF, and IL-6. After 24 hours in culture, some WTcells were treated once with increasing concentrations of olaparib or0.01% DMSO for an additional 3 days. We used 4 nM olaparib as alow-concentration dose, as this is below the IC50 for the drug; 0.1 and5 μM olaparib were used as the moderate and high concentrations,respectively. After 4 days in culture, cell phenotypes were determinedby FACS. The viability of MDSCs was not affected by any condition (FIG.41A). PARP-1 inhibition by a low or moderate concentration of olaparibexerted no effect on the percentage of CD11b⁺/Gr1⁺ MDSCs generatedduring the differentiation process (FIG. 36A). Interestingly, the highconcentration of the drug (5 μM) increased the number of the examinedMDSCs. PARP-1 heterozygosity did not increase the percentage of MDSCs,but similarly to the high olaparib concentration, PARP-1 knockoutsignificantly increased the MDSC population (FIG. 41B). It is noteworthythat the prevalence of MDSCs in tumors of APC^(Min/+) PARP-1^(−/−) micewas also higher than that in tumors of APC-^(Min/+) mice (FIG. 42).Gr1⁺-MDSCs from the different experimental groups were co-cultured atday 4 with CFSE-labeled WT CD3⁺ T cells. Proliferation of T cells wasassessed 3 days later by FACS. The co-culture assay was conducted in theabsence of olaparib. WT MDSCs were efficient at suppressing theproliferation of T cells (FIG. 36B). Such suppressive activity wassignificantly reduced even after treatment with the low olaparibconcentration of 4 nM. The moderate and high concentrations blocked thefunction of MDSCs completely, and this result was mirrored by PARP-1heterozygosity. The low concentration of olaparib exerted no effect onproliferation of T cells (FIG. 36C); however, despite the inhibition ofthe moderate and high concentrations of olaparib of MDSC function, suchconcentrations exerted significant effects on T-cell proliferation (FIG.36C), consistent with our previous studies using primary human T cells(9). To determine whether the effects of PARP inhibition on MDSCs were,at least in part, responsible for the effects on tumorigenesis, weadoptively transferred bone marrow-derived in vitro-differentiated WTMDSCs into MC-38 cell-based tumors in PARP-1^(+/−) mice. Since apharmacological approach is not appropriate to address the question, weused PARP-1+/− mice as a model for partial PARP inhibition. FIG. 36Dshows that adoptive transfer of MDSCs into WT mice exerted no effect onthe size of the tumors, and this result is consistent with the report bySceneay et al. (22). Administration of WT MDSCs into tumors ofPARP-1^(+/−) mice, however, temporally abrogated the effects of PARP-1heterozygosity, resulting in increased tumor size. Interestingly, thetumor tended to shrink to the level observed in control PARP-1^(+/−)mice a few days after the increase, and a second administration of MDSCsreversed the tumor size to that observed in tumors of WT mice.

In an effort to determine the mechanism(s) by which PARP-1 regulatesMDSC function, we next explored the effect of PARP-1 inhibition on theexpression of key factors, such as iNOS, ARG-1, and COX2, which areknown to play a major role in the ability of MDSCs to suppress T-cellproliferation (12, 23). We conducted a time course and followed theexpression of these factors during the differentiation process; alltreatments with olaparib were performed once, starting 24 hours afterplating. An expected gradual increase in ARG-1, iNOS, and COX2 uponstimulation with GM-CSF/G-CSF/IL-6 was observed (FIG. 36E). MDSCsappeared to be extremely sensitive to treatment with olaparib, as the 4nM concentration was sufficient to prevent the increase in ARG-1, iNOS,and COX2 observed in control cells; however, the pattern of the effecton ARG-1 was different from that of iNOS and COX2. ARG-1 expression wasnot affected during the first 24 h of treatment with eitherconcentration of olaparib. The downregulation of ARG-1 occurredbeginning at 2 days of treatment. The decrease in the aforementionedfactors was associated with a reduction in p53 phosphorylation.Surprisingly, only the low concentration of olaparib increased theoverall levels of STAT3 with a concomitant increase in itsphosphorylated α and β forms. The inhibitory effects of the low and highconcentrations of olaparib on ARG-1 and iNOS were also observedfollowing stimulation of MDSCs by cancer cells through a co-culture withMC-38 cells (FIG. 36F). Similar results were observed when the 3LL lungcarcinoma cell line was used as the stimulus (FIG. 36G). The specificityof the relationship between ARG-1 and PARP-1 was verified using MDSCsderived from bone marrow of PARP-1^(+/−) mice (FIG. 36G). Furthermore,the addition of olaparib to PARP-1^(+/−) MDSCs co-cultured with 3LLcells did not dramatically change the effect on ARG-1 expression.Overall, the above results demonstrate that PARP-1 plays a critical rolein MDSC function, that these cells are highly sensitive to inhibition ofthe enzyme, and that this effect is key to the protective effects of lowdoses of olaparib against tumor formation.

The modulatory effect of low-dose olaparib on MDSC function isindependent of PARP-1 trapping to chromatin

The principal mechanism by which PARPi achieve cytotoxic effects onBRCA-mutant cancer cells is by trapping PARP-1 to breaks in thechromatin induced by exposure to DNA-damaging agents (2). Thus, wedetermined whether the effect of olaparib on MDSC function is related tothis process. MDSCs were treated with different concentrations ofolaparib for 12 h, and then nuclear and chromatin fractions wereisolated. PARP-1 remained primarily in the nuclear fraction aftertreatment with the different concentrations of olaparib (FIG. 36H). FIG.36I shows PARP-1 trapping on DNA chromatin following treatment of JurkatT cells with the DNA-damaging agent VP-16. The low concentration ofolaparib promoted little to no trapping of PARP-1 on the chromatin,while the high concentration of olaparib promoted substantial trapping,and these findings reflected the extent of DNA damage as indicated bythe level of phosphorylated H2AX (γH2AX).

A metronomic dose of olaparib synergizes with anti-PD1 therapy toeradicate MC-38 cell-based tumors in mice

It is important to acknowledge the unlikely scenario in which low dosesof PARPi are adopted in the clinic based on the concern of potentiallysubjecting patients to unacceptable risks. However, without wishing tobe bound by theory, this strategy may be ideal for the enhancement ofexisting anti-cancer immunotherapies, such as checkpoint blockers (24).We, thus, examined the efficacy of a metronomic dose (0.2 mg/kg onalternate days) in enhancing the anti-tumor effect of anti-PD-1 therapy(100 μg/mouse administered every 4 days) in the MC-38 cell-based model.As expected, anti-PD1 and olaparib, individually, significantly reducedthe progression of MC-38 tumors in WT mice (FIG. 37A). Interestingly,the efficacy of the low dose of olaparib in reducing tumor size wascomparable to that promoted by anti-PD1 therapy. Remarkably, however,the combination was substantially more effective at blocking tumorprogression. In fact, some mice displayed complete tumor remission. Theefficacy of a low dose of olaparib and anti-PD-1 therapy was reproducedusing MC-38 cells transfected with a GFP- and luciferase-expressingplasmid. Tumors in mice from the different experimental groups wereexamined using biophotonic imaging (FIG. 37B), and the luciferaseactivity signal in the different tumors was determined (FIG. 37C),further indicating the significant synergy between the metronomic doseof olaparib and anti-PD1 therapy. Specificity to PARP-1 was verifiedwith the same approach using PARP-1^(+/−) mice (FIG. 37D). All forms oftreatment either partially or completely prevented the tumor-associatedincrease in spleen size (FIG. 37E). Similarly, all forms of treatmentreduced systemic inflammation, although anti-PD-1 or its combinationwith olaparib exerted a more pronounced reduction in MCP-1 and IL-6(FIG. 37F). Given the eradication of tumors by the combination ofolaparib and anti-PD1, only a few tumors were large enough to be usedfor protein extraction followed by immunoblot analysis. While both thelow dose of PARPi and anti-PD1 immunotherapy induced an increase inPD-L1 in tumors, the combination therapy was associated with a decreasein PD-L1 (FIG. 37G). The overall activation of caspases-3, -7, -8, and-9 was higher in tumors isolated from animals treated with olaparib,anti-PD1 therapy, or the combination of both treatments. There was aconcomitant increase in γH2AX, which may be due to DNA breaks generatedupon stimulation of the caspase-activated endonuclease. An increase inp21/Wafl in these groups indicated a simultaneous increase in cell cyclearrest (FIG. 37G, lower panels). Surprisingly, all forms of treatmentinduced a moderate increase in PARP activation, as assessed byimmunoblot analysis with antibodies to poly(ADP-ribosyl)ated proteins.

Finally, the strong synergy between a metronomic dose of olaparib andanti-PD1 therapy required verification in a different colon cancermodel. Therefore, we used the more aggressive colon carcinoma cell lineCT-26, which has a BALB/c genetic background. Although a low dose ofolaparib promoted a statistically significant reduction in tumor size inBALB/c mice, especially early during the protocol, the overall effectwas marginal (FIG. 37H). The anti-PD1 therapy also proved efficient inthis model but not to the extent of that observed in the MC-38cell-based model. The effect of the combination of treatments, however,was substantially better at reducing the tumor burden in this model,revealing a significant synergy between the two therapies. These resultswere mirrored by effects on spleen size (FIG. 371). The tumors in thismodel were sufficiently large to determine that anti-PD1 treatmentpromoted a slight, but statistically significant, increase in thepercentage of MDSCs, which was reduced to control levels by olaparibtreatment (Supplementary FIG. S6). Overall, these results indicate asignificant synergy between a low dose of olaparib and anti-PD1 therapy.

Discussion

The status of anti-cancer therapy is undoubtedly unsatisfactory, andmuch remains to be done to increase the efficacy of current strategiesin order to provide additional viable options to affected individuals toimprove their quality of life. The results of our studies unravel anunexpected role for PARP-1 in regulating MDSC function, providing aparadigm-shifting concept that may be applied not only to colon cancerbut also to all conditions that reap benefits from immunotherapy. Ourdata demonstrate that targeting MDSC function with a low dose ofolaparib provides an impressive effect on tumor growth alone, and moreimportantly, this olaparib treatment synergizes with anti-PD1immunotherapy. The superiority of partial PARP-1 inhibition compared toextensive inhibition was demonstrated in several models, increasing ourconfidence in the relevance to human disease. The concept is thatmodulation of the suppressive function of MDSCs within the tumormicroenvironment using metronomic doses of PARPi provides an advantageto the immune system to attack the tumor and to prevent its progressionor promote its regression. The addition of immunotherapy, such asanti-PD1, ensures the maintenance of a robust anti-tumor response.

The ultimate goal of high doses of PARPi-based therapy is the promotionof synthetic lethality in BRCA-mutated cancer cells (1). Although thisconcept is appealing and is theoretically expected to affect only thecancer cell, the reality is that such therapy also affects normalhealthy cells. Indeed, moderate and high doses of PARPi have been shownto be immunosuppressive ((1, 2), see FIG. 35D). While such effects maybe counterintuitive when checkpoint blockers are considered, results ofsome clinical trials using a combination of high doses of PARPi andimmunotherapy to target lung cancer with a high mutation rate werepromising (reviewed in (1)); however, the long-term beneficial ordetrimental effects remain to be determined. In a very recent single-armphase II clinical trial, the combination of durvalumab, an anti-PD1antibody, plus a maximal dose of olaparib (600 mg/daily) did not meetthe primary set endpoint in patients with relapsed small cell lungcancer (25). An important observation from this study that needs to bementioned is that 60% of patients exhibited significant lymphopenia and50% displayed leucopenia indicating important immunosuppression. PARPitherapy aims at increasing the mutation rate of cancer cells to promotethe generation of a higher number of neoantigens in such a way thatimmunotherapy becomes more effective; yet, it may not selectivelyachieve the intended goal, as it is also expected to increase mutationsin genes that may elevate tumor progression, resistance to therapies,and recurrence. Despite the recent application of PARPi-based therapy,there are concerns regarding resistance to PARPi (1). However, withoutwishing to be bound by theory, the use of metronomic doses of PARPi isunlikely to cause similar side effects, as the outcome of such treatmentmay be limited to a portion of the immune cell populations and may notexert any direct DNA repair-associated alterations in the cancer cell.Further validation of the efficacy of metronomic doses of PARPi incombination with immunotherapy can be attained through clinical testing.The metronomic chemotherapy concept is not very new; however, itsadoption in the clinic has been limited (14, 15). With the developmentof precision medicine, interest in this concept is becoming moreapparent. Dalgleish and Stern (15), in a very elegant and objectiveexamination of the status and potential of this concept in currentanti-cancer therapies, propose that investigators focus attention on thenotion that “less can be more”, perhaps not only enhancing anti-tumortherapy efficacy but also sparing patients from many of the lifequality-reducing side effects of the therapies.

Migration of MDSCs to tumors is critical both for their activation andtheir suppressive activity against T cells. In several studies, wedemonstrated that PARP inhibition either genetically orpharmacologically via moderate doses of PARPi affects the migration ofeither Th1 or Th2 inflammatory cells into sites of injury (9). Weattributed this effect to a reduction in several chemokines, includingMCP-1, and adhesion molecules, such as ICAM-1. It is rather puzzlingthat PARP inhibition did not affect the migration of MDSCs into tumors,despite the clear reduction in systemic MCP-1 and intratumoral ICAM-1.These results suggest that MDSCs do not require large amounts of thechemokines or adhesion molecules for intratumoral migration.

What is clear from our results is that MDSC function is highly sensitiveto PARP inhibition and that such effect is not associated with PARP-1trapping on the chromatin. A sub-IC50 concentration and dose of olaparibwere capable of reducing the suppressive capacity of MDSCs in vitro andex vivo, respectively. The low concentration of the drug did not promotePARP-1 trapping on the chromatin, suggesting that the mechanism by whichPARP inhibition reduces MDSC function is unrelated to its role in DNArepair. In addition, the effect of PARP inhibition on MDSC function alsoappears to be durable, as MDSCs isolated from tumors of olaparib-treatedmice remained, at least partially, incapable of regaining theirsuppressive function, despite the fact that the assay was performed inthe complete absence of the drug ex vivo. Equivalent concentrations ofolaparib or other PARPi do not exert any major effects on cancer cells(10). Interestingly, the primary mechanism by which PARP inhibitionmodulates the suppressive activity of MDSC appears to be via reductionof the expression of factors necessary for the function of these cells.An effect by PARP inhibition on iNOS and COX2 may be predictable becausethese proteins can be regulated by several factors, including NF-κB andSTAT6, that PARP-1 influences. However, the mechanism by which PARP-1inhibition reduces ARG-1 levels appears to be different, as the effectswere not evident until after 24 h of treatment. The levels of ARG-1 werealways low in PARP-1^(+/−) MDSCs, suggesting that long-term inhibitionof PARP is necessary for ARG-1 downregulation. As stated above, olaparibinhibits both PARP-1 and PARP-2. The addition of the drug toPARP-1^(+/−) MDSCs did not change the effect on ARG-1 expressionsuggesting a potentially specific relationship between ARG-1 and PARP-1but not PARP-2. Efforts to identify the transcription factor(s) that istargeted by PARP inhibition both in terms of expression levels andposttranslational modifications provided no concrete conclusions, asmany of relevant transcription factors were not affected during theprocess of MDSC differentiation in vitro. A more comprehensiveinvestigation is required to decipher the exact signaling mechanism bywhich PARP-1 influences MDSC function. Nevertheless, our currentfindings are certainly translatable and can serve as a platform forimmediate clinical trials.

Currently, there are several clinical trials examining the combinationof PARPi and checkpoint blockers. The primary goals of these trials areto test whether checkpoint blockers enhance efficacy of PARPi in avariety of cancers or to explore the potential of PARPi in increasingthe rate of mutations to promote a greater number of neoantigens. Thedoses used in these trials are not different from those used as amonotherapy, and few trials propose dose-escalation strategies.Embodiments described in the present work are quite different and doesnot target the cancer cell. Instead, embodiments herein target MDSCs.Without wishing to be bound by theory, the present invention will notonly expand the utility of FDA-approved PARPi but will also reviveinterest in PARPi with a low-to-moderate capacity to trap PARP-1 ondamaged chromatin. Such expansion will undoubtedly increase the optionsavailable to cancer patients and may have immediate clinical benefits.Very recently, Jiao et al. (26) reported that olaparib, at a dose of 50mg/kg daily, enhances anti-PD1 immunotherapy in an allograft breastcancer mouse model, although the PARPi used in the study promotedimmunosuppression with a concomitant upregulation of PD-L1 expression.Such effects appeared to be independent of the immune system, since itmanifested in a breast cancer xenograft model. In our experimentalsystem, a low dose of PARPi also induced an increase in PD-L1 in tumors,an effect that is not different from that induced by anti-PD1immunotherapy. Interestingly, combination therapy was associated with adecrease in PD-L1. Although it is difficult to explain this result, itis possible that the lower levels of PD-L1 are associated with thepredicted increase in cell killing and proteasomal activity that isknown to regulate the fate of the protein. Unlike in whole tumors, thelow and high concentrations of olaparib exerted opposing effects onMC-38 cell-stimulated PD-L1 expression in MDSCs (FIG. 44), and notably,the MC-38 cells, in our hands, did not express PD-L1 in either theabsence or presence of olaparib. Again, high concentrations of PARPihave been shown to be immunosuppressive, and such an effect can bedetrimental as a robust immune system to attack tumor cells is neededfor immunotherapy success. Furthermore, the use of high doses of PARPiwill undoubtedly lead to undesired side effects and potential resistanceto the drugs. More problematic is the fact that these doses willultimately promote genomic instability of cancer cells as well as normalcells, ultimately leading to additional complications. This notion issupported by our results in the APC' mouse model, in which completeinhibition of PARP-1 by gene knockout actually aggravated the tumorburden instead of providing protection as PARP-1 heterozygosity. Wereported this dichotomy several years ago in a conference report(Paradoxical roles of PARP-1 in colon inflammation and tumorigenesis;FASEB J. Vol. 29, No. 1_supplement April 2015) and was supported by arecent study that reported that complete inhibition of PARP-1 by genedeletion increased the AOM/DSS-induced tumor burden when combined withamplified DNA damage via deletion of the DNA repair geneO⁶-methylguanine-DNA methyltransferase (18). In addition to enhancingthe effects of immunotherapy, PARPi may mitigate colitis or cachexia,which are prominent side effects of immunotherapy and cancer in general,respectively. Our observation of the effect of olaparib on cachexia isconsistent with a recent study that showed that in a diaphragm andgastrocnemius model of lung cancer with the LP07 adenocarcinoma cellline, PARP-1 (and PARP-2) gene knockout partially protected againstcachexia (27).

In conclusion, our results will provide extraordinary opportunities forimmediate clinical trials. Without wishing to be bound by theory, theresults of such trials can benefit a large proportion of cancerpatients. Our findings highlight the notion that targeting the cancercell with PARPi should not always be the main goal, as targeting cellsof the immune system may allow us to treat additional cancer types inaddition to BRCA-mutated breast or ovarian cancer with this therapeuticmodality.

Materials and Methods

Animals and genotyping: C57BL/6 or BALB/c WT mice and C57BL/6APC^(Min/+) mice were purchased from Jackson Laboratories (Bar Harbor,Me.) and allowed to acclimate prior to experiments. PARP-1^(+/−) micewere maintained on a C57BL/6 background as described previously (28) andinterbred to generate PARP-1^(−/−) mice or crossed with APC^(Min/+) miceto generate APC^(Min/+)/PARP-1^(/) mice. Male APC^(M)″^(m+)PARP-1^(+/−)were crossed with PARP-1^(/) females to generate APC^(Min/+)/PARP-1^(/)mice. All mice were housed in a specific pathogen-free facility atLSUHSC (New Orleans, La.) in a 12-hour light:12-hour dark photoperiodwith unlimited access to sterilized chow and water. Maintenance,experimental protocols, and procedures were all approved by the LSUHSCInstitutional Animal Care and Use Committee (IACUC). The different mousestrains were genotyped using DNA extracted from tail snips according tostandard protocols with primer sets specific for PARP-1, APC, orAPC^(Min) (IDT, Coralville, Iowa) and recommended by JacksonLaboratories (Supplementary Table S1).

Cell isolation, culture, treatments, RNA extraction, cDNA synthesis andquantitative PCR—Primary CEC were isolated essentially as described(29). The mouse colon adenocarcinoma (MC-38 or CT-26), Jurkat T,RAW264.7, or 3LL lung carcinoma cell lines were purchased from Kerafast(Boston, Mass.) or ATCC (Manassas, Va.). Mouse embryonic fibroblastswere derived from WT, PARP-1^(+/−), or PARP mice using standardprotocols. CEC were serum-starved overnight in 0.5% FBS prior totreatment. Treatment with 2 μg/ml LPS (Sigma-Aldrich, St Louis, Mo.) or10 ng/ml TNF-α (Roche Diagnostics Corp, Indianapolis, Ind., USA) wasconducted in starving medium. MC-38 and CT-26 cells were cultured inRPMI medium supplemented with 10% FBS and 1% penicillin/streptomycin,29.2 mM Hepes, 2 mM L-glutamine, and 0.03 mM β-mercaptoethanol. Jurkat Tand 3LL cells were grown in RPMI or DMEM, respectively, supplementedwith 10% FBS and antibiotics. At 85-90% confluency, attached cells weretrypsinized and suspended in PBS to a final density of 1×10⁶ cells/ml.For in vitro studies, 0.5-1×10⁶ cells were seeded for 24 h prior totreatment. Total RNA was extracted using a RNA extraction kit (Qiagen,Valencia, Calif.) according to the manufacturer's instructions. RNA wasused to generate cDNA using reverse transcriptase III (Invitrogen,Carlsbad, Calif.). PCR was done using previously validated primer sets(IDT) specific for mouse TNF-α, IL-6, MCP-1, or β-actin (SupplementaryTable S1) (30-32). Quantitative determination of gene expression levelsusing a 2-step cycling protocol was conducted on a MyIQ Cycler (Bio-Rad,Hercules, Calif., USA). Relative expression levels were calculated usingthe 2[Delta Delta C(T)] method. Quantities of all targets werenormalized to the mouse β-actin gene.

CD3⁺ T cells were isolated from spleens of naive WT mice using MagniSortMouse T-cell Enrichment Kit (eBioscience, San Diego, USA) according tothe manufacturer's instructions. The Purity of the enriched T-cells wastested by FACS analysis using antibody to mouse CD3 (BD, Franklin Lakes,N.J.). Bone marrow-MDSCs were generated by incubating bone marrow cellswith a cocktail of either 20 or 40 ng/ml of GM-CSF, G-CSF, and IL-6. Fortumor MDSCs, MC-38-engrafted tumors were harvested and digested withliberase (Roche) and DNase I (Sigma-Aldrich) solution for 45 minutes at37° C. Myeloid cells were then isolated using EasySep Mouse CD11bPositive Selection Kit (Stem Cell, Vancouver, Canada); purity of MDSCswas assessed by FACS analysis with antibodies to mouse CD11b(eBioscience) and Gr-1 (BD, Franklin Lakes, N.J.). To conduct thesuppression assay, T cells, tumor- or bone marrow-derived MDSCs wereco-cultured with T cells labeled with carboxyfluorescein diacetatesuccinimidyl ester (CFSE) (Life Technologies, Carlsbad, Calif.) at aratio of 1:8. The co-culture was conducted in plates that werepre-coated, overnight, with 1 μg/ml of CD3 (clone 145-2C11) and CD28(clone; 37.51) (BD, Franklin lakes, USA). T cell proliferation wasassessed 72 h later by FACS.

Tumor models, assessment of tumor burden and adoptive transfer—For theazoxymethane/Dextran Sulfate Sodium (AOM/DSS)-induced tumorigenesismodel, six to eight weeks old WT, PARP-1^(+/) or PARP-1^(/) micereceived a single dose (10 mg/kg) of AOM, i.p., followed by 4 cycles of1.25% DSS provided in drinking water. Each cycle consisted of a week ofDSS water separated by 2 weeks of regular water. In some experiments,AOM/DSS-treated WT mice were administered, i.p., 5 or 25 mg/kg(Selleckchem, Tex.) of olaparib or vehicle twice a week starting at week2 until the end of the protocol. At week 22 after the start of theexperimental protocol, mice were sacrificed by CO₂ asphyxiation. Colons,spleens, and blood were collected for analysis. Colons were openedlongitudinally and washed with PBS to assess the tumor burdens using adissecting microscope. For the APC^(Min)-mediated model, APC^(Min/+),APC^(Min/+)PARP-1^(+/−), or APC^(Min/+)PARP-1^(−/−) male mice weresacrificed at 16 weeks of age. Some APC^(Min/+) mice received i.pinjections of olaparib starting at week 6 for 10 weeks. Sacrificed micewere processed as described above except that the tumor burden wasassessed along the whole intestinal track. Tumors were counted anddivided in groups lower than 2 mm, 2-4 mm, and tumors bigger than 4 mmin diameter.

For the syngeneic tumor models, six to eight weeks old WT, PARP-1^(+/−),or PARP-1^(−/−) mice were subcutaneously inoculated with 2.5×10⁵ MC-38cells. In some experiments, MC-38 cells transfected with p193-PGK-SB100Xand pKT₂PGK-BsdGFP_CLP-Luc plasmids (flanked by Sleeping Beautytransposons) and sorted by FACS. Selected cells were then engrafted ontomice as described above. When tumors became palpable (at day 4-6), WTmice were randomized and assigned to the different experimental groups.Some WT mice received i.p injections of olaparib in doses of 0.2, 5, or25 mg/kg three times per week and others received i.p. anti-mouse PD-1(CD279) antibodies (100 μg/mouse) or isotype control (BioXCell, N.H.,USA) twice per week. Tumor volumes were measured with a digital caliperor assessed using GFP/Luc-Biophotonic Imaging (Xenogen IVIS200,PerkinElmer, Boston, Mass.). Tumors were measured by the greatestlongitudinal diameter (length) and the greatest transverse diameter(width) using a digital caliper. Tumor volumes were calculated using thefollowing formula: tumor volume=(length×width²)/2. For luciferaseimaging, tumor-bearing mice received 150 mg/kg of D-luciferin potassiumsalt solution (PerkinElmer, Boston, Mass.) i.p. five minutes prior toanesthetic induction and imaging. Bioluminescence within a predeterminedregion of interest (ROI) on each mouse was quantified inphotons/sec/cm²/sr. At the end of the protocol (day 20-24), mice weresacrificed and tumors were harvested for further processing andanalysis. For the adoptive transfer experiments, 3×10⁶ BM-MDSCs derivedfrom WT mice or vehicle were injected, intratumorally, into WT orPARP-1^(+/−) mice. The MDSCs were delivered at five injection sites atdays 8 and 16 following engraftment of MC-38 cells.

Tissue processing, immunohistochemistry, immunofluorescence andcytokines measurement—Some tissues were fixed in buffered formalin(10%), paraffin-embedded, then sectioned. Serial sections were subjectedto H&E staining, immunohistochemistry (IHC) or immunofluorescence, asdescribed (33), with antibodies to PCNA (Novusbio, Littleton, Colo.),COX-2 (Santa Cruz Biotechnology, Santa Cruz, Calif.), ICAM-1 (Santa CruzBiotechnology), CD8 (Santa Cruz Biotechnology), or Gr1 (eBioscience, SanDiego, USA) as previously described (34). Some of the sections weresubjected to immunofluorescence with antibodies to CD8 or Grl. Blood,collected by cardiac puncture, was run through a Microtainer SerumSeparator tube (BD, Franklin Lake, N.J.). The collected sera wereimmediately stored at -80° C. for future use and analysis. Cytokinelevels were assessed for TNF-α (ELM-TNFα-1), IL-6 (ELM-IL-6-1), andMCP-1 (ELM-MCP1) by ELISA (all from RayBiotech, Norcross, Ga.) accordingto the manufacturer's instructions and recommendations.

Cell fractionation, protein extraction and immunoblot analysis—Tumortissues or cells were harvested and homogenized in RIPA lysis buffer(Santa Cruz Biotechnology) containing a cocktail of protease andphosphatase inhibitors on ice. Nuclear fractions were isolated asdescribed (35) and the remaining chromatin pellets were washed thensuspended in an isotonic buffer followed by sonication. Protein extractswere subjected to immunoblot analysis essentially as described (9) withantibodies against PARP-1 (1:1000, MA5-15031, Invitrogen), cleaved (p85)PARP-1 (1:1000, 9541, Cell Signaling), cleaved caspase-3 (1:1000, 9664,Cell Signaling), cleaved caspase-7 (1:1000, 9491, Cell Signaling), ARG1(1:1000, 610708, BD), COX-2 (1:1000, 4842, Cell Signaling), p53 (FL-393)(1:1000, sc-6243, Santa Cruz Biotechnology), phospho-(S15) p53 (1:1000,9284, Cell Signaling), phospho-(S37) p53 (1:1000, 9289, Cell Signaling),STAT3 (1:1000, 9132, Cell Signaling), phospho-(Y705) STAT3 (1:1000,9131, Cell Signaling), γH2AX (1:1000, H5912, Sigma-Aldrich), Anti-GRB2(1:1000, 610112, BD), PD-L1 (1:1000, 66248, Proteintech), cleavedcaspase 9 (Asp315) (1:1000, 9505, Cell Signaling), caspase 8 (1C12)(1:1000, 9746, Cell Signaling), p21/Wafl/Cip1 (1:1000, 2946, CellSignaling), PAR (1:1000, 4335, Trevigen), GAPDH (G-9) (1:1000,sc-365062, Santa Cruz Biotechnology), Histone 3 (H3) (1:1000, D2B12,Cell Signaling), tubulin (1:1000, 3873, Cell Signaling), actin (C-2)(1:1000, sc-8432, Santa Cruz Biotechnology); the last four antibodieswere used to detect control proteins. Protein expression signalsdeveloped by ECL (Pierce, ThermoFisher Scientific) were determined by aG:Box Gel Image Analysis System (Syngene, Cambridge, UK) equipped withthe GeneSys image capture software.

Flow cytometric characterization of tumor infiltrating immune cellsusing fluorescence-activated cell sorting (FACS) analysis—Followingdigestion, tumor homogenates were filtered through a 70 μM cell strainerto obtain a single cell suspension. Cell suspensions were then subjectedto red blood cell lysis using ACK buffer for 5 minutes beforeresuspending in complete media. Cells were treated with anti-CD16/CD32(BD; 2.4G2) for Fc blocking prior to staining with fluorescently-labeledmouse antibodies specific for CD45 (30-F11), CD3e (500A2) (both fromeBioscience, San Diego, Calif.), Ly6C (AL-21), Ly6G (1A8), Gr1(RB6-8C5), CD11b (M1/70), CD8 (53-6.7), and PD-1 (PA5-J43) (all from BDBiosciences, San Jose, Calif.). Single cells were gated by first usingforward- and side-scatter doublet discrimination. Immune cells werediscriminated from this doublet-excluded population using CD45. Myeloidcells were identified using a CD11b⁺gate and MDSC subtypes identified byGr1 selection and then plotted Ly6G/Ly6C. CD3⁺ T-cells were gated fromCD45⁺ cells. CD4⁺ and C8⁺ T-cells were identified from CD3⁺ gate. Thedetailed gating strategy is described in FIG. 45.

Statistical analysis—All data are presented as mean ±standard error ofmean (SEM). Analysis of the variance for the different groups (sameexperiment) was conducted using a one-way ANOVA followed by Tukey'smultiple comparison test. When a comparison is conducted between twogroups, an unpaired Student t-test was used. These analyses werefacilitated by the PRISM software (GraphPad, San Diego, Calif.).

REFERENCES CITED IN THIS EXAMPLE

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SUPPLEMENTARY TABLE 1 PCR primer sequences Gene Sequence β-actinForward: 5′-TAC AGC TTC ACC ACC ACA GC-3′Reverse: 5′-TCT CCA GGG AGG AAG AGG AT-3′ ICAM-1Forward: 5′-GTG ATG CTC AGG TAT CCA TCC A-3′Reverse: 5′-CAC AGT TCT CAA AGC ACA GCG-3′ iNOSForward: 5′-TCT TCG AAA TCC CAC CTG AC-3′Reverse: 5′-CCA TGA TGG TCA CAT TCT GC-3′ IL-6Forward: 5′-CTG GAA GAG ACT TCC ATC GAG-3′Reverse: 5′-AGT GGT ATA GAC AGG TCT GTT GG-3′ TNF-αForward: 5′-CAT CTT CTC AAA ATT CGA GTG ACA A-3′Reverse: 5′-TGG GAG TAG ACA AGG TAC AAC CC-3′ VCAM-1Forward: 5′-TGC CGA GCT AAA TTA CAC ATT G-3′Reverse: 5′-CCT TGT GGA GGG ATG TAC AGA -3′ PARP-1Forward: 5′-CAT GTT CGA TGG GAA AGT CCC-3′Reverse 1: 5′-CCA GCG CAG CTC AGA GAA GCC A-3′Reverse 2: 5′-AGG TGA GAT GAC AGG AGA TC-3′ APCWT: 5′-GCC ATC CCT TCA CGT TAG-3′Common antisense: 5′-TTC CAC TTT GGC ATA AGG C-3′APC^(Min): 5′-TTC TGA GAA AGA CAG AAG TTA-3′

Example 6

Protocol for Anti-PD-LI+PARPi Synergy Experiments:

Six to eight weeks old WT mice will be subcutaneously inoculated with2.5×10⁵ MC-38 cells (or other cancer models). Mice will be randomizedand received i.p injections of olaparib, such as in doses of 0.2, 5, or25 mg/kg three times per week, and others received i.p. anti-mouse PD-L1(clone B7-H1) antibodies (such as 100 μg/mouse) or isotype (LTF-2)control (BioXCell, N.H., USA) twice per week. Mice may also be treatedwith anti-EGFR (clone 225) or anti-VGEF-R2 (clone DC101) to examine thesynergy between PARP inhibitors with non-check point inhibitorimmunotherapy. Tumor volumes will be measured with a digital caliper orassessed using GFP/Luc-Biophotonic Imaging (Xenogen IVIS200,PerkinElmer, Boston, Mass.). Tumors will be measured by the greatestlongitudinal diameter (length) and the greatest transverse diameter(width) using a digital caliper. Tumor volumes will be calculated usingthe following formula: tumor volume=(length×width²)/2. For luciferaseimaging, tumor-bearing mice will receive 150 mg/kg of D-luciferinpotassium salt solution (PerkinElmer, Boston, Mass.) i.p. five minutesprior to anesthetic induction and imaging. Bioluminescence within apredetermined region of interest (ROI) on each mouse will be quantifiedin photons/sec/cm²/sr. At the end of the protocol (day 20-24), mice willbe sacrificed and tumors were harvested for further processing andanalysis.

Example 7

Asthma is a serious health issue worldwide and a common treatment forthe disease is a combination of corticosteroids with a β2-agonist;however, many patients are refractory to these and other establishedtreatments. A major limitation in steroid-based asthma is thedevelopment of resistance where allergic airways can be refractory toanti-inflammatory treatment. Individuals with steroid-resistant asthmahave limited therapeutic options; some can die by status asthmaticus.steroid-resistant asthma is intimately associated with neutrophilicinflammation with a primary increase in IFNγ. Our findings demonstrate acritical role for PARP-1 in steroid resistance in asthma and lendsupport to the potential of PARP inhibition as a viable therapeuticstrategy for the treatment of steroid- resistant asthma.

Example 8

PARP inhibitors such as olaparib (LYNPARZA®) or rucaparib (Rubraca®) andothers (under clinical trials) are used to target cancer cells with BRCAmutations with an ultimate goal to achieve synthetic lethality (death ofonly mutant cancer cells). However, this therapy is primarily effectivein BRCA-defective cancers (FDA-approved for advanced ovarian cancer;LYNPARZA is also approved in Europe for BRCA-mutated HER2(−) metastaticBreast Cancer). The ultimate goal of this therapy is maximal inhibitionof PARP to achieve “synthetic lethality” taking advantage of theinability of BRCA-deficient cancer cells to repair DNA. This strategy islimited by the requirement for a constant administration of high dosesof PARP inhibitors and the alarming rise of resistance to the drugs. Weshow that PARP inhibition (by knockdown or a low dose of olaparib)promotes an increase in glucocorticoid receptor (GR) phosphorylation inlung and immune cells. This was initially pertinent to the observationthat PARP inhibition reverses steroid resistance asthma in a mouse modelof the condition. We predicted that this discovery may provide immediateclinical impact in the context of steroid-resistant cancers such asleukemia, lymphoma, colon cancer, and many others. Usingsteroid-resistant leukemia cells with a very low dose of olaparib (4 nM)that is close to its IC50 completely reversed sensitivity of the cellsto dexamethasone (corticosteroid). We also determined the lowest dosecombination that can achieve maximum killing; we found we can use as lowas 0.1 nM dexamethasone and 0.008 nM AZD2281 to kill 50% of the cells.The concentration of AZD2281 is more than a million times lower thanwhat is routinely used in similar research. This was tested in threedifferent leukemia cell lines. Such effect was linked to a decrease inNOTCH1; the combination of dexamethasone and the low dose of olaparibpromoted a marked decrease in NOTCH1, NOTCH3, and HES1 (NOTCH target)levels. The combination of olaparib and dexamethasone did not affect theproliferation of PBMCs isolated from healthy individuals. This indicatesthat we may expect to cause a specific effect in leukemia cells withoutaffecting normal immune cells. The addition of ultra-low doses ofγ-secretase inhibitors (GSIs) (currently in clinical trials: 1 nMPF-3084014 or 25 nM BMS-906024) significantly increased the efficacy ofdexamethasone and olaparib. Of note, the concentration of GSIs used inour studies do not have major effects on NOTCH1 levels or cellproliferation of leukemia cells. The combination of γ-secretaseinhibitors with olaparib (all at low doses) was also efficacious at cellkilling and at reducing NOTCH1 and HES1 (and several proteins that arekey for cell survival and/or proliferation). Moreover, the combinationof 0.5 μM dexamethasone and 4 nM olaparib with 1 nM PF-3084014 or 25 nMBMS-906024 was far more efficacious at killing leukemia cells (KOPT-K1and T-ALL1 cell lines) with a complete elimination of NOTCH1 and HES1.Thus, without wishing to be bound by theory, PARP inhibitors can be usedin combination with steroids (i.e. Olaparib+Steroids) or γ-secretaseinhibitors (i.e. Olaparib+γ-secretase inhibitors) or with the twoclasses of drugs (i.e. Olaparib+Steroids+γ-secretase inhibitors) toreverse steroid resistance not only in leukemia but in also any cancersthat are being targeted with steroids. Furthermore, these combinationscan be used to enhance sensitivity to steroids in steroid-responsivecancers, which may lead to a de-escalation of steroid doses(steroid-sparing) and subsequent decrease/elimination of associated sideeffects.

PARP inhibitor olaparib LYNPARZA® or rucaparib/Rubraca®) are prescribedto only women with advanced BRCA-mutated ovarian cancer (also approvedfor BRCA-mutated Her2(−) metastatic breast cancer in Europe). Thisdisclosure claims that PARP inhibitors, at very low doses, can be usedto reverse steroid resistance or enhance sensitivity to steroids in allcancers that can be targeted with steroids. The second claim is that lowdoses of PARP inhibitors can synergize with steroids to inhibit theNOTCH pathway. This combination may not be limited to steroid-resistantcancers or cancers that are targeted with steroids. Another claim isthat PARP inhibitors, again at very low doses, can enhance the efficacyof NOTCH inhibitors. In this case, NOTCH inhibitors can be used at IC50or sub-IC50 doses. In addition to synergy of PARP and γ-secretaseinhibitors, this combination may allow the use of low NOTCH inhibitorsin many cancers and reduce the potential side effects.

There is no reported connection between steroids and low doses of PARPinhibitors. Similarly, there are no reports showing a synergy betweenPARP inhibitors with γ-secretase inhibitors with or without steroids.This technology can be applied in a variety of cancers (liquid or solid)in addition to many non-neoplastic diseases in which steroids are used.The stated combinations may lead to de-escalation of steroid doses,which is a highly desirable clinical approach to prevent resistance orenhance sensitivity to steroids in patients. Given that PARP inhibitorsand steroids are already FDA-approved, the clinical impact to benefit alarge portion of cancer patients may be immediate. Also, severalγ-secretase inhibitors have already been tested in clinical trialsbeyond Phase 1; their combination with PARP inhibitors with or withoutsteroids may be tested in clinical setting in a rather fast manner. Theincreased efficacy of γ-secretase inhibitors when combined with lowdoses of PARP inhibitors (with or without steroids) may open a majorpotential for a success of this new class of drugs.

Example 9

Poly(ADP)Ribose Polymerase inhibition by olaparib or gene knockoutrestores steroid sensitivity in a mouse model of steroid-resistantAsthma

Background: Asthma is a serious health issue worldwide and a commontreatment for the disease is a combination of corticosteroids with aβ2-agonist; however, many patients are refractory to these and otherestablished treatments. A major limitation in steroid-based asthma isthe development of resistance where allergic airways can be refractoryto anti-inflammatory treatment. Individuals with steroid-resistantasthma have limited therapeutic options; some can die by statusasthmaticus. steroid-resistant asthma is intimately associated withneutrophilic inflammation with a primary increase in IFNy. Ourlaboratory has established a critical role for poly(ADP-ribose)polymerase (PARP) in asthma and induction of hyperresponsiveness (AHR).Additionally, we and others have demonstrated an important role forPARP-1 in neutrophilic inflammation. Thus, it became plausible tohypothesize that PARP-1 may reduce or completely restores steroidsensitivity in steroid-resistant Asthma.

Objective: To investigate whether PARP inhibition could restore steroidsensitivity to block LPS/IFN-γ-induced neutrophilia and AHR in steroid-resistant asthma model of the disease. Methods: Anovalbumin/LPS/IFNγ-based model of steroid-resistant murine asthma and anairway epithelial cell culture system were used in this study.

Results: Sensitization to and challenge with OVA promotes a Th2 responsethat is completely blocked by treatment with the corticosteroid;dexamethasone. Priming of the OVA with LPS/ IFNγ resulted in immuneclass switching of eosinophils into neutrophils that became resistant totreatment with corticosteroid. PARP inhibition by gene knockout orpharmacologically by olaparib (5 mg/kg) reversed the establishedsteroid-resistant asthma manifestation in mice. These effects wereattributed to a marked reduction in Th2 cytokine production without aprominent effect on the anti-inflammatory cytokine IL-10. PARPinhibition blocked the infiltration of inflammatory cells into theairways with significant reduction in the neutrophils, eosinophils,macrophages and lymphocytes recruited into the lungs of OVA challengedmice. Such effect was associated with marked reduction in OVA-specificIgE secretion in both BALF and serum of mice. PARP inhibition-associatedreversal of steroid resistance was also associated with an increase inglucocorticoid receptor expression as observed in IL-27treatedmacrophages

Conclusion: Our findings demonstrate a critical role for PARP-1 insteroid resistance in asthma and lend support to the potential of PARPinhibition as a viable therapeutic strategy for the treatment ofsteroid- resistant asthma.

Example 10

NOD-SCID-Gamma2 humanized mice engrafted with human CD34+ cells will bepurchase from Jackson Laboratories with already established patientderived leukemia cells injected i.v. via tail vein of animals. Thismodel has been developed to better mimic tumor heterogeneity, the tumormicroenvironment, and cross-talk between the tumor and stromal/immunecells. These features make them extremely valuable models for theevaluation of investigational cancer therapies, specifically newimmunotherapies. The humanized mouse xenograft models are essential tobetter understand the interactions between the human tumor and itsenvironment.

The mice will be randomly divided into different experimental groupsthat will received the following treatment as soon as the tumors areestablished: (i) DMSO, (ii) different doses of steroids (such as,dexamethasone), (iii) Olaparib or other PARP inhibitors (at doses lowerthan 1 mg/Kg), or (iv) a combination of Olaparib or other PARPinhibitors with steroids.

After a predetermined time period (depends on the leukemia cells used),mice will be anesthetized ventral side up using isoflurane. The footpinch reflex will be used to confirm proper anesthetization. Ophthalmicointment will be applied to both eyes for prevention of cornealdesiccation while under sedation. The tumor burden will be assessed inthe spleen, bone marrow, and lymph nodes of animals as well as in othertissues using macroscopic and microscopic techniques. Blood will also beprocessed for cell count and sera for cancer-related factors.

These experiments will be repeated using syngeneic mouse models usingcompatible leukemia cell lines

EQUIVALENTS

Those skilled in the art will recognize, or be able to ascertain, usingno more than routine experimentation, numerous equivalents to thespecific substances and procedures described herein. Such equivalentsare considered to be within the scope of this invention, and are coveredby the following claims.

What is claimed:
 1. A composition comprising a dose of PARP inhibitorsufficient to reduce the activity of PARP by about 10-50 percent and atleast one additional anti-cancer agent or anti-inflammatory agent. 2.The composition of claim 1, wherein the at least one additionalanti-cancer agent is a γ-secretase inhibitor, a steroid, a checkpointblockade inhibitor, or any combination thereof 3.-7. (canceled)
 8. Amethod for treating a tumor in a subject, the method comprisingadministering to the subject afflicted with the tumor a low-dose,therapeutically effective amount of a PARP inhibitor compound and atleast one additional anti-cancer agent or anti-inflammatory agent.
 9. Amethod of reducing progression or promoting regression of a tumor in asubject, the method comprising administering to the subject afflictedwith a tumor a low-dose, therapeutically effective amount of a PARPinhibitor compound and at least one additional anti-cancer agent oranti-inflammatory agent.
 10. A method of reducing cellular proliferationof a tumor cell in a subject, the method comprising administering to thesubject afflicted with a tumor cell a low-dose therapeutically effectiveamount of a PARP inhibitor compound and at least one additionalanti-cancer agent or anti-inflammatory agent.
 11. The method of claim 8,wherein the PARP inhibitor compound inhibits PARP-1, PARP-2, PARP-3,PARP-4, PARP-5a, PARP-5b, PARP-6, PARP-7, PARP-8, PARP-9, PARP-10,PARP-11, PARP-12, PARP-13, PARP-14, PARP-15, PARP-16, or any combinationthereof
 12. The method of claim 8, wherein the PARP inhibitor compoundcomprises a compound of Formula (I):


13. (canceled)
 14. The method of claim 8, wherein the low dose,therapeutically effective amount comprises no more than about 1 mg/kgbody weight.
 15. (canceled)
 16. The method of claim 8, wherein the lowdose, therapeutically effective amount of the PARP inhibitor compoundreduces the activity of a PARP by about 10-50 percent.
 17. The method ofclaim 8, wherein the PARP inhibitor compound modulates the tumormicroenvironment.
 18. The method of claim 17, wherein the PARP inhibitorcompound reduces the activity of myeloid derived suppressor cells(MDSCs).
 19. The method of claim 8, where the tumor comprises a solidtumor or a liquid tumor.
 20. (canceled)
 21. (canceled)
 22. The method ofclaim 8, wherein the tumor comprises a steroid resistant tumor .
 23. Themethod of 8, wherein the formation and/or growth of the tumor isexacerbated by chronic inflammation.
 24. The method of claim 8, whereinthe PARP inhibitor compound is administered as a pharmaceuticalcomposition.
 25. (canceled)
 26. The method of claim 8, wherein the atleast one additional anti-cancer agent is an anti-PD1 antibody, aγ-Secretase inhibitor, or a steroid.
 27. The method of claim 8, whereinthe PARP inhibitor compound and at least one other anti-cancer agent oranti inflammatory agent is administered in a single dose.
 28. The methodof claim 8, wherein the PARP inhibitor compound and at least one otheranti-cancer agent or anti-inflammatory agent is administered atintervals of about 4 hours, 12 hours, or 24 hours.
 29. The method ofclaim 8, wherein the PARP inhibitor compound and at least one otheranti-cancer agent or anti-inflammatory agent is administered orally,intraperitoneally, subcutaneously, intravenously, or intramuscularly.30. The method of claim 8, wherein the anti-cancer agent compoundcomprises a compound of Formula II: